03/16/2020

Correct Billing for 28285 -3 Toes-LT (50 X 3 Units)

Procedure: 28285 3 toes on right foot and 3 toes on left foot Orthonet (healthfirst) Authorized 28285 (50) x 3 units. Question is how to bill this? Previously I had a patient that was bilateral 5th toes and auth also said 50 modifier and was only paid for one toe, appealed and appealed with no correction. This case is 6 toes, I am unsure how to bill with the 50modifier in this case, is it 3 lines each with a 50 modifier x 1 unit or is one line with 50 modifier x 3 units etc?

The correct way to have billed this is on 6 lines with the corresponding T Modifier.  Bilateral is stating its being done on the same toe different sides, because you are able to use the actual T Modifier to distinguish the different toes.

However, in order to be reimbursed for the surgery for all six units by Healthfirst at this time, you can try submitting the claim coded exactly as the authorization from Orthonet was obtained. Try billing three lines on the claim, each line with modifier -50. To distinguish that the procedure was done on each toe, each line must be billed with the corresponding-T modifier pair that describes a bilateral procedure. Below is the list of modifiers that should be billed together on one line after modifier-50, dependent on the op-reports from the DOS: So select the correct combination from the list below.

-TA/-T5

-T1/-T6

-T2/-T7

-T3/-T8

-T4/-T9

If the claim is partially denied, an appeal should be filed with op-reports to show the medical necessity of the surgery along with the pre-certification from Orthonet to show that authorization protocol with the managed care plan was followed.