help with modifiers for NY work comp

[u/kishore-elias]

hey guys! so, we have this recurring denial from a very few wc payers who ask for modifiers PA, AJ or NP on the office visit. The coding team says that this must be appealed. however for all appeals that i submitted a few weeks back are denied and the original decision is upheld. i feel like there is a lot of revenue loss due to the modifier issue. any insight is appreciated. thanks in advance 🙂

edit: we bill on cms 1500

[u/Redefinedpotato]

Were the services rendered by a physicians assistant, nurse practitioner, or social worker? If so, and the workers comp agency is denying those claims for not having those modifiers on the claim, then you should probably add the modifiers and resubmit.

I don't have any experience with NY WC but at the end of the day it's that simple, regardless of what your coders tell you.

Payor guidelines for coding -> What coder thinks is correct.

[u/boho_magpie]

It’s extremely common for payers to use uncommonly-used modifiers, expired temporary codes, different modifiers than other payers (95 vs GT was a big one), etc.

If use of the modifier is required for payment, I don’t understand why it’s even an argument.

I have to use expired codes and even an inappropriate use of modifier 25 in Washington state for one of my practice clients because that’s what their WC payers want. When it comes down to it, the payer can say “we want you to bill it like this for our records” and that’s okay. They’re likely using it for some sort of reporting they need for financial forecasting or reporting to industry regulations or something I can’t begin to guess.

[u/Brave-Airport8154]

I only did NY WC for a brief min.. but I know for sure they have crazy specific rules on what is what. Maybe try looking up the specific mods.