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Thread: MODIFIERS for billing

  1. #1
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    Idea MODIFIERS for billing

    We are searching for a modifier that can be used for Caresource/Medicaid for 92310 and v2520. A representative from caresource stated that they use the same modifiers as listed on cms.gov but we are unable to locate the modifiers on their site. If anyone has a list of modifiers to use with vision icd10 codes, it would be greatly appreciated. We are learning as we go. Thank you!!

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    These are some that my organization uses. I am not a billing/coding specialist, so I won't be able to answer questions about the context for each modifier.
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  3. #3
    My Brain Hurts jpways's Avatar
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    What are you trying to submit?

    The only modifiers I can think of that would apply for those 2 codes are:
    For V2520, you need RT and LT and the quantity has to be 2
    Do no use modifier 50 (bilateral) for this as that does not apply to any ophthalmic materials
    Now for 92310, the only modifiers that I can think of that medicare uses are 52 (reduced services) and 22 (Unusual services). 52 is used for when a service is not as complicated as a normal service. An example of this would be if you have an existing contact lens patient and the Dr. doesn't need to do a full workup to renew the contact lenses prescription (and if that definition is confusing to you, I'm sorry, I've never had a situation where that modifier truly applies to 92310, so I made some up) then I would submit that claim with 92310-52. As for modifier 22, I've never tried to submit a claim with this and technically it's only for surgical procedure but if you do enough research the only CPT codes that this modifier truly does not apply to are the E&M codes (those that start with 992). This modifier makes the statement that this procedure was so out of the ordinary and required so many extra visits that payment higher than the "average service" payment is necessary. You have to have sufficient documentation to prove that the service was sufficiently abnormal and complicated that the application of this modifier is necessary. With that being said all CPT codes are for the average service, so using this modifier for a multifocal fit is probably not correct.

    Now, if coresource is looking for modifiers that say that this was a daily wear, extended wear, monovision, etc. fit those codes simply do not exist under medicare rules.

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    We are having some MAJOR issues with Geisinger insurance claims and was wondering if anyone else is in the same situation. Until 2022, we have not had any issues at all and now something changed. As of 2022, all routine eyewear has been rejected for V2020 siting an absence of modifier. We never used a modifier for a frame and got paid before with no issues. We did try resubmitting with RT or LT and even RT and LT and it was still rejected. We were told by a rep that maybe it wasn't the modifier and maybe it was just that they didn't know if it was post op or routine eyewear (although the diagnosis was on there). So we resubmitted again with an additional note stating routine eyewear to help those that couldn't figure out the diagnosis codes. Still rejected. Now they sent us a claim edit rationale with LCD codes which make no sense to me. (EY,GA,GY,GZ,KX) When I looked these codes up, it seems to me that none of these would apply to a V2020 routine eyewear claim. We are now going to have to drop Geisinger for materials if this continues. Anyone have any thoughts or advise? (also...we contacted our rep to to find out they are no longer our rep)

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    I would ask your medical biller about modifier KX. We have used it with success on some VSP claims where they only allow Otis and Piper frames but the child is too big to fit into one of them.

    What does the KX modifier mean?



    Modifier KX

    Use of the KX modifier indicates that the supplier has ensured coverage criteria for the billed is met and that documentation does exist to support the medical necessity of item. Documentation must be available upon request.





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    Thanks! I will look into this. I appreciate the advise.

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    Quote Originally Posted by NAICITPO View Post
    I would ask your medical biller about modifier KX. We have used it with success on some VSP claims where they only allow Otis and Piper frames but the child is too big to fit into one of them.

    What does the KX modifier mean?



    Modifier KX

    Use of the KX modifier indicates that the supplier has ensured coverage criteria for the billed is met and that documentation does exist to support the medical necessity of item. Documentation must be available upon request.




    KX is also the modifier for "Gift of Sight" Gift certificates.

    Otis &Piper (children) and Genesis Collection (adult) are the only lines allowed for coverage.

    [Note: This is a restarted thread at post #4]

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