Q&A: Third-party payer contradicting MAC guidance

CDI Strategies - Volume 18, Issue 8

Q: According to one of our private carriers, we should report bilateral services with modifier -50 (bilateral procedure) for physician claims in one of the following ways:

  1. Report modifier -50 on two service lines with 1 unit each
  2. Report modifier -50 on one service line with 2 units of service

However, the carrier does not have this in its payment policies. In addition, this private payer’s instruction contradicts other private carriers and our Medicare administrative contractor (MAC). What should we do?

A: It can be frustrating when a payer doesn’t spell out its policies, or its policies conflict with guidelines from official sources. Fortunately, there are steps you can take when this happens.

But first, practices should understand that “the AMA has guidance on how to report modifier -50, but the AMA doesn’t pay claims,” said Doris Branker, CHC, CPC, CIRCC, CPMA, CPC-I, CANPC, CEMC, principal consultant for DB Healthcare Consulting & Education in Sunrise, Florida.

Payers often exercise the right to decide how they want providers to report claims. Branker added, but you have a couple of options “depending on how much effort you want to exert.”

You can “trust them and test it,” Branker said. “That is, bill it the way they’re telling you to bill it [and test] to see whether or not you’ve been paid bilaterally.” That means you must know your allowables. “Because sometimes they’ll tell you to do that and then you only get paid for 1 unit,” Branker said.

That’s the easier route. If you’re willing to spend more time and effort, you can file an appeal when a carrier doesn’t have a published policy and they also deviate from the AMA guidelines.

“Escalate it and require them to publish a policy. Because you’re causing a denial — or an underpayment. So, if I bill it according to AMA — either a denial or underpayment would warrant them being able to escalate that and require the payer to do what they’re required to do,” Branker said. 

Editor’s noteThis Q&A originally appeared in JustCoding. A version of this article was originally published in Part B News.

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Ask ACDIS, Denials & Appeals

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