Hi Wanted to see if we are able to bill a 99232 and 90966 together. there’s a lot of issues I see with the claim as 90966 was billed at the beginning of the month vs the end of the month. pt went to the ED several times that month which claims were billed with 99232. Medicare denied claims for 99232 stating we would need to append a mod as claims are bundling.
I was told that I should use the 90970 instead of the 90966?
I’m lost on this
You might want to check out the Medicare Claims Processing Manual, Chapter 8, Section 140.2. It provides scenarios for physician billing when caring for home dialysis patients, including patients who have been hospitalized during the month.
The Renal Physicians Association has billing and coding information that may be helpful too.
https://www.renalmd.org/page/coding-billing
The problem you’re having is a direct consequence of the NCCI PTP edits that only affects the home dialysis codes and not the in-center dialysis codes.
What is happening is that 90966 covers the entire month (with caveats). The 99232 is an inpatient claim used on a single day that should be outside of the 90966 outpatient claim. However, in what appears to be an error in the NCCI PTP edits, the 99232 is denied as a sort of duplicate claim occurring on the same day already reimbursed by the 90966…. unless you append a modifier. Except, CMS (or any of the MACs) won’t tell you what modifier to use or even if there is a modifier.
Of course, this only applies if the same TIN/NPI combination submitting the 99232 is also the same combination submitting the 90966 per NCCI program rules. In other words, a solo practitioner will always fall into this trap. A partner (different NPI) from the same group submitting the 99232 would be reimbursed without requiring the modifier. Notably, this combination issue does not affect in-center patients so you never see a denial with 99232 and 90962, for example.
But none of this should ever happen in the first place because 99232 is an inpatient code and should be bypassed in all 90966 cases. CMS needs to update the Correct Coding Modifier Indicator (CCMI) for home dialysis codes from 1 to 9 for this to work properly.