Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for CPT code 27130 without modifier 22. We decided that the Plan does not have to pay for modifier 22.

You asked the Plan to pay for CPT code 27130 with modifier 22. You say that the medical records support the billing of CPT code 27130 with modifier 22. The Plan says that the medical records do not support the billing of CPT code 27130 with modifier 22.

We decided that the Plan has to pay for CPT code 27130.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27130 is Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for CPT code 27130 with modifier 22. Our reviewer says that the medical records support the billing of CPT code 27130. Our physician reviewer found the CPT code for hip replacement CPT 27130 should be approved but the extra work modifier #22 is not supported. The operative note does not support the extra work code. Not enough documentation is present to justify the extra work code. Hip replacement surgery was performed but the extra work beyond what is covered in the code is not supported in the documentation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 27130 without modifier 22 have been met. Therefore, we decided that the Plan has to pay for CPT code 27130.

We also decided that the Plan does not have to pay for modifier 22.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for CPT code 27130 with modifier 22. Our reviewer says that the medical records support the billing of CPT code 27130. Our physician reviewer found the CPT code for hip replacement CPT 27130 should be approved but the extra work modifier #22 is not supported. The operative note does not support the extra work code. Not enough documentation is present to justify the extra work code. Hip replacement surgery was performed but the extra work beyond what is covered in the code is not supported in the documentation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 27130 with modifier 22 have not been met. Therefore, we decided that the Plan does not have to pay for modifier 22.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.