4: The procedure code inconsistent with the modifier used or a required modifier is missing

On Call Scenario:

                                                      Claim denied as procedure code 
                                                    inconsistent with the modifier used
                                                                              ↓
                                                           May I get the denial date?
                                                                              ↓

                                             Check patient payment history if the same

                                                 CPT code paid with the same modifier

                                                ↙                                                              ↘
                                           Yes                                                                No
                                             ↓                                                                   ↓
                 Can you please reprocess the claim as                  What is the time limit to 
            payment received for same CPT & modifier?             send corrected claim?
                                             ↓                                                                   ↓
                    What is the TAT for reprocessing?                   What is the Fax# or Mailing 
                                             ↓                                                 address to send an appeal?
                   May I have the claim# & call ref#?                                       ↓
                                                                                              How much is the time limit 
                                                                                                      to send an appeal?
                                                                                                                  ↓
                                                                                          May I have the claim# & call ref#?

Important Note:

• This denial should be assigned to the coding team to review and provide the correct modifier and once a response is received with the correct modifier details then send the corrected claim to insurance by updating the correct modifier even if the time limit to send the correct claim is crossed.
• If the coding team states that the modifier is correct then send an appeal to insurance.
• When sending an appeal, calculate the time limit from the denial date, if it is not crossed then send the appeal, or else write off the claim if the time limit is crossed.
• Sometimes the client wants us to send the appeal even if the time limit is crossed, so work accordingly.
• There will be a scenario where the same CPT is billed with the LT and RT modifiers and one of them is already paid and the other is denied as an invalid modifier, in that scenario insurance needs to send the CPT in a single line by using bilateral modifier(50). So void both the CPT and create a new line with a 50 modifier which will double the charge amount and send the corrected claim to insurance.
• Medicare does not accept the corrected claim, so first send the void claim for paid CPT to insurance then send a new claim with a 50 modifier.

Prepare Notes:

Source of Status:

* Call Website EOB System

Clearing House Comment (Please make the changes if required):

Insurance Name:

*

Clearing House Name:

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Denial Date:

*

Has payment found for the same CPT with same modifier in the patient payment history?:

* Yes No

What Information is Available?:

* Corrected Claim Time Frame Appeal Information Corrected Claim Time Frame and Appeal Information None

TAT for Reprocessing:

*

Corrected Claim Time Frame:

*

Mode of appeal:

* Fax Mail Website

Fax Number:

*

Mailing Address:

*

Website Link:

*

Appeal Limit:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Need coding assistance Updated correct modifier and resubmitted the claim Updated correct procedure and resubmitted the claim Need client assistance Need to send an appeal Need to allow time Appeal Sent



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