Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epidurography services (72275-26-59) and moderate 
sedation services (99153) provided on October 28, 2021. 
 
You asked the Plan to pay for the services as billed. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the documentation does not support 
payment for the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that for services paid via the 
PFS, each code is assigned both physician work and PE RVUs. PE RVUs are often reduced for physician 
services rendered in the facility setting. Since payment for many PE expenses, such as staff wages and supplies, 
is included in Medicare payment to the facility, payment associated with those resource costs is not made under 
the PFS. The rules also state specifically that nursing services and supplies provided in an ASC are included in 
the ASC payment rate for the procedure. 
 
The code 99153 has a Pro/Tech flag of 3 in the PFS. This indicator identifies stand- alone codes that describe 
the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an 
associated code that describes the professional component of the diagnostic test only. The total RVUs for 
technical component only codes include values for practice expense and malpractice expense only.  
 
Because code 99153 does not include physician work but reimburse PE RVUs, the services described by this 
code are nursing/technician services and supplies. Payment for this is made to the ASC facility and cannot be 
paid to the physician. As such, payment to the physician for code 99153 in the ASC setting is not allowed. 
Based on this information, the Medicare rules for payment of code 99153 have not been met. 
 
In this case, we have confirmed that code 72275 is a column II code to column I code 64483; however, 72275 
was billed with a modifier.  
 
We asked our coder 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 the services as billed. Our reviewer says that the 
documentation does not support separate payment for CPT code 72275. Our reviewer found in this case, 
separately reporting the radiological supervision and interpretation cannot be verified as a separate procedure. 
Per CPT guidelines "Codes 64455, 64479, 64480, 64483, 64484 are reported for single or multiple injections on the same site.  For 64479, 64480, 64483, 64484, imaging guidance (fluoroscopy or CT) and any injection of 
contrast are inclusive components and are not reported separately". The use of the 59 modifier to bypass the 
edits is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the epidurography services (72275-26-59) and moderate sedation services (99153) 
provided on October 28, 2021.