Medicare billing - How to avoid denial

To avoid appeal

  Document a repeat or duplicate service to reflect it is as a distinct and separate service. Failure to document a repeat or duplicate service will result in a denial.

    * Report modifier 76 to indicate a procedure or service was repeated subsequent to the original procedure or service.
    * Report body site modifiers to indicate more than one of the same service is performed but on different body parts sites, e.g. LT, RT, TA – T9
    * Report modifier 59 modifier to indicate a distinct procedural service.  This may represent a different session or patient encounter, different procedure or surgery, different site, or organ system, separate incision/excision, or separate injury (or area of injury in extensive injuries).
    * Report clarifying information pertaining to repeat or duplicate services using block 19 of the CMS-1500 (08-05) claim form or in the Extra Narrative Data segment (Loop 2300/2400) of the ANSI ASC X12 837 Versions of an electronic claim.  Utilize this field to report the time of each subsequent or repeat service or the number of times this service needed to be performed.



 Submit supporting documentation with the claim when certain modifiers e.g. 52 or 22 are appended to the service or when a LCD or NCD indicates documentation is required. Failure to submit the documentation will result in a denial.

    * Modifier 22 represents increased procedural services and when the work required to provide a service is substantially is greater than typically required. Documentation must support the substantial additional work and the reason for the additional work (e.g. increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required)..

    * Modifier 52 represents reduced services and when under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion.  The explanation can be submitted by entering the information block 19 of the CMS-1500 (08-05) claim form or in the Extra Narrative Data segment (Loop 2300/2400) of the ANSI ASC X12 837 Versions of an electronic claim or submitting the supporting documentation.

    * Documentation can be submitted when a CMS-1500 claim is filed or if the claim is submitted electronically a  “Cover Sheet for Submitting Medical Documentation for Electronic Claims” form, must be completed.