Resolved Anesthesia modifier

[JessicaF_91119]

1. Hi I have a 2 cases that I would like some coding advice.
Patient has ruptured breast implants removed anesthesia billed 00402, patient then developed a hematoma and had to return to the OR another anesthesiologist billed 00560. HF denied CPT 00560 as bundled for same day similar procedure. Can I add modifier 78 for this scenario?

2. my provider/facility billed 00104 and a different provider of another facility is billing 90870, 00104 is being denied as bundled to 90870 and no modifier can unbundle this relationship. But since my facility didn't perform this procedure a completely different provider and specialty should I bother to appeal this?

 

[Darcy]

1. Hi I have a 2 cases that I would like some coding advice.
Patient has ruptured breast implants removed anesthesia billed 00402, patient then developed a hematoma and had to return to the OR another anesthesiologist billed 00560. HF denied CPT 00560 as bundled for same day similar procedure. Can I add modifier 78 for this scenario?

2. my provider/facility billed 00104 and a different provider of another facility is billing 90870, 00104 is being denied as bundled to 90870 and no modifier can unbundle this relationship. But since my facility didn't perform this procedure a completely different provider and specialty should I bother to appeal this?

1.
Yes, in this scenario, you can likely add modifier 78 to the anesthesia code (CPT 00560) to indicate an unplanned return to the operating room for a related procedure to manage the hematoma that developed after the initial ruptured breast implant removal, even though the procedures occurred on the same day, as the insurance company may consider it bundled; however, always consult with your billing specialist to confirm based on the specific details of the case and your payer's guidelines.

Why modifier 78 is appropriate here:

• Unplanned return to OR:
  The patient's need to return to the operating room to address the hematoma was not anticipated during the initial procedure, making it an unplanned return.
• Related procedure:
  The second procedure (hematoma management) is directly related to the first procedure (ruptured implant removal).
• Different provider (if applicable):
  While not always necessary, if a different anesthesiologist performed the second procedure, it further strengthens the argument for using modifier 78.
  

Important considerations:

• Payer specific rules:
  Always check your payer's specific billing guidelines to ensure modifier 78 will be accepted in this situation.
• Documentation is key:
  Thorough documentation in the medical record is crucial to support the need for a separate anesthesia code with modifier 78, including details about the unexpected hematoma development and the subsequent return to the OR.

 

[Darcy]

1. Hi I have a 2 cases that I would like some coding advice.
Patient has ruptured breast implants removed anesthesia billed 00402, patient then developed a hematoma and had to return to the OR another anesthesiologist billed 00560. HF denied CPT 00560 as bundled for same day similar procedure. Can I add modifier 78 for this scenario?

2. my provider/facility billed 00104 and a different provider of another facility is billing 90870, 00104 is being denied as bundled to 90870 and no modifier can unbundle this relationship. But since my facility didn't perform this procedure a completely different provider and specialty should I bother to appeal this?

2.
Based on the information provided, you should still consider appealing the denial of code 00104, even though it's bundled with 90870 billed by another provider, as the fact that a different facility and specialty performed the service could be a strong argument in your favor, especially if you can clearly document this distinction in your appeal.

Key points to consider:

• Different Provider and Specialty:
  Since a different provider from a different facility performed the service, you can argue that the "bundled" concept doesn't apply in this situation as the services were not rendered by the same entity.
• Medical Necessity Documentation:
  Provide detailed medical documentation supporting the necessity of the 00104 procedure, highlighting how it was distinct from the 90870 service provided by the other provider.
• Review the Insurance Policy:
  Carefully examine your payer's specific policy regarding bundled codes and if there are any exceptions for different providers or specialties.
  

What to do when appealing:

• Gather evidence:
  Collect all relevant medical records, billing codes, and documentation that clearly demonstrate the separate nature of the services provided by your facility and the other provider.
  
  
• Precise explanation:
  When crafting your appeal, explain the situation thoroughly, emphasizing that your facility did not perform the procedure associated with code 90870 and why 00104 is medically necessary in this context.
  
  
• Contact the payer:
  Reach out to the insurance company directly to discuss the denial and see if they have any specific requirements for appealing bundled code denials related to different providers.