PRV1_0119_ProviderManual-Commercial.pdf

Cpt modifier description charges units 31238

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CPT Modifier Description $ Charges Units 31238 Nasal/sinus endoscopy, surgical, with control epistaxis $500.00 – units 1 31238 -50 Nasal/sinus endoscopy, surgical, with control epistaxis $500.00 units 1 Example 2: Billed as one line (two services). CPT Modifier Description $ Charges Units 31238-50 Nasal/sinus endoscopy, surgical, with control epistaxis $1,000.00 units 1 To ensure accurate payment, please make sure you bill the full billed amount, rather than the precut amount. Our system will not recognize if the claim has been precut, and it will cut again according to bilateral surgery guidelines.
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Section 11 | Billing Requirements 68 11.5.2 Multiple Procedures Multiple surgeries are separate procedures performed during the same operative session or on the same day, for which separate billing is allowed. Please be aware that this applies to both professional and hospital/ facility charges: • When multiple procedures, other than E&M services, are performed on the same day or at the same session by the same provider, the primary procedure or service should be reported as listed. • Any additional procedures or services should be ranked in descending Relative Value Unit (RVU) order and identified by the use of modifier -51 on each additional procedure/service. • Procedure codes that are classified as multiple procedures in the CMS Billing Manual will be processed according to our multiple procedure guidelines. If the code is modifier -51 exempt or an add-on code, it will be processed using 100 percent of the contracted allowed. Six or more procedures will require review by PacificSource and chart notes may be requested. PacificSource uses the following payment structure for multiple procedure claims. Be sure to bill full charges for all services in order to receive the correct payment. • Primary procedure: 100 percent of the fee allowance Second procedure: 50 percent of the fee allowance Third through fifth procedures: 25 percent of the fee allowance Idaho and Montana PacificSource uses the following payment structure for multiple procedure claims. • Primary procedure: 100 percent of the fee allowance Second procedure: 50 percent of the fee allowance Third through fifth procedures: 50 percent of the fee allowance To ensure accurate payment, please make sure when you are billing for multiple procedures that you submit the full billed amount, rather than the precut amount. Our system will not recognize the claim has been precut and will cut again according to the multiple surgery guidelines. 11.5.3 Multiple and Bilateral Surgical Procedures Performed in the Same Operative Session Selected bilateral eligible services may also be subject to multiple procedure reductions when billed alone or with other multiple procedure reduction codes. When two or more procedure codes subject to reductions are performed on the same date of service and are subject to reduction as defined in the Federal register, only one of the procedure codes will be considered as the primary procedure, and all the remaining procedures will be considered secondary.
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  • Winter '16
  • Dr. Vincent Onyebuchi
  • PacificSource

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