“We have had more than one claim where Blue Cross Blue Shield of Oklahoma is paying for CPT 28122 but denying CPT 28306, despite the use of the 59 modifier. Our question is why wouldn’t CPT 28306 be allowed instead of CPT 28122 as it is far more work? We are trying to determine how to appeal this.”
So, CPT code 28306 (Osteotomy, with or without lengthening, shortening or angular correction, metatarsal first metatarsal) and CPT code 28122 (Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (e.g. osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus) were both performed and billed for on the same date of service. CPT code 28122 was reimbursed, but CPT code 28306 was not despite the use of the 59 modifier. What could be going on?
Well, at face value, CPT code 28122 is the Column 1 code to CPT code 28306 the Column 2 code within the CCI edits. Based upon this premise, CPT code 28306 would not be separately reimbursable. However, one must look at the entire scenario in order to determine if it is justified to bill both of these CPT codes together.
I am making the assumption that both of these CPT/procedure codes were not performed on the first metatarsal. If they were both performed on the first metatarsal, the CCI edits would prevail and only CPT code 28122 would be reimbursable. Therefore, I am assuming that CPT/procedure code 28306 was performed on the first metatarsal and CPT/procedure code 28122 was performed on one of the lesser metatarsals on the same foot. If that was indeed the case, you would think that billing both of the CPT/procedure codes appended by the appropriate foot modifier (ie. RT, LT) and CPT/procedure code 28306 additionally appended by the 59 modifier to indicate a “Distinct Procedural Service” would allow for reimbursement of both CPT/procedure codes, but obviously it did not. It is possible that, in lieu of the 59 modifier, it might be more appropriate to append CPT/procedure code 28306 with the XS modifier (-XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure). Based upon the preference of Blue Cross Blue Shield of Oklahoma, the XS modifier could very likely be favored over the 59 modifier as it certainly is more specific. If that does not achieve reimbursement, an appeal would certainly be in order.
I would first contact BCBS of Oklahoma and ask to speak to a supervisor, with all due respect, in the United States and initially I would speak to this individual about what has transpired and perhaps you will be able to achieve some clarity and closure with respect to how to handle this situation to possibly avoid filing an appeal. I would make sure that I received the process in writing and I would be sure to obtain the name and ID number of the supervisor. If the only option is to appeal the decision, I would follow the appeals process of BCBS of Oklahoma as it is stated on the website. I would make sure that I would submit a corrected claim, one that has the XS modifier appended to CPT/procedure code 28306. Additionally, I would make sure that a copy of the operative report was submitted, as well.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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