Forum - Questions & Answers

Nov 28th, 2022 - enb414

61154 - burr hole with 61210 Drain - billing issue

Cigna Medicare is stating that 61154, 61210, and 61781 are all add on codes and they are not wanting to pay them without a primary CPT code. 61781 (stereotactic CT) is usually inclusive but we code it anyway and sometimes it gets paid on but usually not. CMS states that both codes 61154, and 61210,  can be billed independently with 61210 having a modifier of -58 and AANS coding guide states that they can be billed separately (with correct modifier). Is there a modifier that can be used to identify 61154 as a primary procedure code? If not, how do we bill this to get it paid??

Dec 1st, 2022 - ChrisW   256  1 

re: 61154 - burr hole with 61210 Drain - billing issue

CMS does not always assign primary codes with Add-On-Codes (AOCs) as in the example below. In this case, you will need to contact Medicare Advantage to see what code they assigned as the primary code. I would suggest contacting your provider representative for additional assistance on this scenario.  
Here are a few things to consider:
CPT 61781 is an Add-on code — but the CPT Manual, HCPCS Manual, and/or CMS Policy do not designate Primary codes for it.Instead, individual contractors define applicable Primary codes. Anytime a Stereotactic procedure is used, it should be reported as it is not inclusiveIn this case, the primary code is determined by the carrier and may differ with each carrier because this is a Medicare Advantage plan.For reference, UnitedHealthcare designates 61154 as the primary CPT code for 61781; however, this may not be the same code used with Cigna Medicare. Do you feel Modifier 58 is applicable? Or would Modifier 59 be more appropriate? Modifier 59 may be reported to indicate that the two procedures are distinct and separately reportable services under these circumstances.Was there a preauthorization done? If so, they will list the applicable codes that were requested and approved. 

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