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  • Determining the correct modifier

    Question: We need help determining the correct modifier to use on the following claim:

    The patient had YAG in the left eye on Aug. 25, 2020.
    Cataract surgery was performed in the right eye on Sept. 22, 2020.
    Patient came in for an infection in the right eye on Sept. 21, 2020. This office visit claim was denied with adjustment CO-97 "Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed." We resubmitted the claim with the modifier -24 and it was denied again stating, "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present." I called Medicare and was told the modifier is incorrect.

    Should we be appending modifier 24 and 79?

      Answer: All exams performed the day before surgery are considered part of the 10% preop of the surgical allowable and not separately billable. There is no modifier that is appropriate. You'll need to take the claim to appeal. Modifier -79 is never applied to exam codes. Only surgical codes.