The Healthcare Common Procedure Coding System (HCPCS) is designated the national coding standard under the Health Insurance Portability and Accountability Act (HIPAA). HCPCS includes level 1 codes (Current Procedural Terminology [CPT®]) and level 2 codes (HCPCS). Although HCPCS and the International Classification of Diseases, Ninth Revision, Clinical Modification are under the umbrella of HIPAA requirements, covered entities such as Medicaid programs and commercial payers are not mandated to pay for all codes.

Most payers use the Medicare National Correct Coding Initiative (NCCI) edits or proprietary software edit programs (eg, McKesson ClaimCheck) as the basis of their claims payment processes. Unfortunately, not all modifiers are paid by Medicare, Medicaid programs, or commercial payers, and this may result in inappropriate denials.

For example, Georgia Medicaid does not recognize modifier 59. Therefore, payment is not made for certain services that, under CPT and NCCI guidelines, should be paid when circumstances allow overriding...

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