November 14, 2019
I oftentimes bill and E/M code with modifier 25 for an office visit and 92504-50 (1 unit) for the binocular microscopy to Medicare. I get denied on 92504-50 but I am paid on 99212. The denial code is “CO-4 The procedure code is inconsistent with the modifier used or a required modifier is missing” and “M20 Missing/incomplete/invalid HCPCS” or “N519 Invalid combination of HCPCS modifiers.” Then Medicare says no appeal rights are afforded because the claim is unprocessable and I should submit a new claim with the complete/correct information. I don’t understand what’s wrong. Please help.
What’s wrong is that modifier 50, for bilateral procedures, should not be appended to 92504. CPT 92504 is reported only once without modifier 50. Additionally, you probably don’t need modifier 25 on the E/M code to Medicare because there is not a National Correct Coding Initiative (NCCI) edit between the two codes which would warrant modifier 25.
*This response is based on the best information available as of 11/14/19.