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Claim Processing of Biometry

Is your Medicare contractor denying claims for the interpretation of the second biometry, 76519-26 or 92136-26?  Here’s why. 

The 2017 Medicare Physician Fee Schedule that was published in January changed the bilateral indicator from a “3” to a “2”, resulting in a payment change.  Bilateral indicators dictate how bilateral services performed at a single session are paid.  They are defined as follows:

      0 = Payment is based on 100% of the fee schedule amount for a single service.  Do not use 50 modifier.

      1 = Use 50 modifier when performed bilaterally.  Payment is based on 150% of fee schedule amount.

      2 = Procedure is defined as bilateral.  Payment is based on 100% of the fee schedule amount for a single service.  Do not use 50 modifier.

      3 = Payment is based on 100% of the fee schedule amount for each service.  When performed bilaterally, payment is based on 200% of fee schedule amount.

       9 = Concept does not apply

It has been a long-standing policy that the technical component of biometry had a bilateral indicator of “2”, meaning it was a bilateral service, paid one time.  The interpretation (26 modifier), however, has had a bilateral indicator of “3”, meaning pay it for each service (right eye, left eye).  This indicator is now a “2” in the 2017 file. 

We believe the current publication and subsequent denials are an error and await a correction.  We recommend keeping track of the denied claims for now.  An appeal will not be effective as long as the Medicare Physician Fee Schedule contains the indicator of “2” for this component. 

Corcoran Consulting Group will keep you informed of any CMS corrections and how to handle denied claims.  Call us with additional questions or concerns at 800-399-6565.

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