Wiki 64635 and 64636

[iannace22]

Hey guys! Hoping someone can help me out here .. we recently got a denial with Amerigroup (wellpoint) stating 198Precertification/notification/authorization/pre-treatment exceeded, and N362 The number of Days or Units of Service exceeds our acceptable maximum.N674 Not covered unless a pre-requisite procedure/service has been provided.

It was billed
64635 - 50 Units: 1
64636 - RT Units: 1
64636 - LT Units: 1

Is this being billed correctly? What can I do to avoid and fix this denial.

 

[areynaga]

Medicare still wants 50 used on add-on codes (even though that's incorrect by CPT guidelines), so if this is a Medicare replacement plan then they may want it billed 64635-50 & 64636-50.

 

[iowagirl77]

Was this preauthorized, and if so, for how many units? It could be as the response above states, and they want you to bill the second level with bilateral modifier. Did both 64635 and 64636 deny?
Since it also denied for N674, you might see if there are requirements for MBB to be performed prior to this, as some payors require this to be tried for efficacy prior to performing RFA.

 

[whitey86]

I see you are in Pennsylvania - if Medicare advantage plan: code per LCD. If you are performing the procedure in an ASC setting then it is 64635 - RT,LT (first level, two separate lines) per Novitas A56670. ***Remember these codes are limited to no more than (2) sessions, per region, per rolling 12 months.
For me I code for the ASC and the physician side.
Example: ASC 64635 - RT, 64635 - LT. Physician 64635-50, 64636-50. (I'm coding this as a Medicare plan)

As for the denial, I would review past claims if this was performed within 12 months or more than 12 months and also if any MBB's were performed per LCD. Submit all medical records. Pre-cert should have been submitted whether or not it truly needed one. That information you can use to fight with if the insurance stated "no auth required" when in fact it did need one.