Monday, July 12, 2010

Submission of CPT 99000 and 36415 with Modifier 59

BCBS Texas - Submission of CPT 99000 and 36415 with Modifier 59

Blue Cross and Blue Shield of Texas (BCBSTX) regularly evaluates the coding practices of physicians and other providers who submit claims for services. This includes issues such as bundling and use of CPT modifiers.

BCBSTX recently studied use of Modifier 59 (Distinct procedural service) with submission of CPT 99000 (Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory).  Because CPT 99000 is purely an administrative service and not a procedure, BCBSTX considers use of Modifier 59 for this code to be inappropriate.  This inappropriate use of Modifier 59 results in override of a claim system edit that considers CPT 99000 incidental to any other service performed on that date of service, including CPT 36415 for routine collection of venous blood, and results in an overpayment.  Please do not submit claims for CPT 99000 with Modifier 59.
Labels:

0 comments:

Post a Comment

Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download