Question 92134 Denial

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Our office is getting denied for CPT 92134 the only insurance that is denying this is Humana Medicare Adv. I have looked at the LCA's and LCD's to make sure the dx code I am linking to the CPT code is payable and they still continue to deny. Is anyone else having this issue? I'm not sure how to get them to pay?
 

saddie2k

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Was it a frequency issue? Not sure what diagnosis your using but there are sometimes frequency limitations.
 

Rajinder_Dhammi

Networker
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It is happening because of this:

Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina


  • No more than one (1) exam every two (2) months will be considered medically reasonable and necessary to manage the patient whose primary ophthalmological condition is related to a retinal disease that is not undergoing active treatment.*
*Note: Please see next bullet if undergoing active treatment.

  • No more than one (1) exam per month will be considered medically reasonable and necessary to manage the patient with retinal conditions undergoing active treatment. These conditions include wet AMD, choroidal neovascularization, macular edema, diabetic retinopathy (proliferative and nonproliferative), branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema. With the development of treat and extend protocols for patients with wet AMD treated with antiangiogenic drugs, it is expected that SCODI (unilateral or bilateral) will be used for therapeutic decision making and utilized at a maximum of monthly with subsequent less frequency based on the patient treatment protocol and patient response as documented in the medical record.
    In addition, other conditions which may undergo rapid clinical changes monthly requiring aggressive therapy and frequent follow-up (e.g., macular hole and traction retinal detachment) may also require monthly scans.
  • No more than one (1) exam per year will be considered medically reasonable and necessary for patients being treated with CQ and/or HCQ. These patients should receive a baseline examination within the first year of treatment and as an annual follow-up after five years of treatment. For higher-risk patients, annual testing may begin immediately (without a 5-year delay).

Thank you,
Rajinder Singh Dhammi, CPC, CPB
 
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Thank you Rajinder. I am aware of the frequency that is why I do not understand why I keep denied for these codes from Humana. Some of these claims that I am sending out this is the very first OCT that we have ever done on a certain patient and I am still getting denied. I have even appealed all of these claims and attached the LCA with this information showing that we have only billed this once ever and still no luck.
 

lakeeyevicky

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The frequency limits apply even if a different Dr. performed performed the test. We get denials once in awhile because pt also sees a retinal specialist outside of our practice and they performed an OCT recently.
 
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It is happening because of this:

Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina


  • No more than one (1) exam every two (2) months will be considered medically reasonable and necessary to manage the patient whose primary ophthalmological condition is related to a retinal disease that is not undergoing active treatment.*
*Note: Please see next bullet if undergoing active treatment.

  • No more than one (1) exam per month will be considered medically reasonable and necessary to manage the patient with retinal conditions undergoing active treatment. These conditions include wet AMD, choroidal neovascularization, macular edema, diabetic retinopathy (proliferative and nonproliferative), branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema. With the development of treat and extend protocols for patients with wet AMD treated with antiangiogenic drugs, it is expected that SCODI (unilateral or bilateral) will be used for therapeutic decision making and utilized at a maximum of monthly with subsequent less frequency based on the patient treatment protocol and patient response as documented in the medical record.
    In addition, other conditions which may undergo rapid clinical changes monthly requiring aggressive therapy and frequent follow-up (e.g., macular hole and traction retinal detachment) may also require monthly scans.
  • No more than one (1) exam per year will be considered medically reasonable and necessary for patients being treated with CQ and/or HCQ. These patients should receive a baseline examination within the first year of treatment and as an annual follow-up after five years of treatment. For higher-risk patients, annual testing may begin immediately (without a 5-year delay).

Thank you,
Rajinder Singh Dhammi, CPC, CPB
Can you please tell me where you found this information. I am drawing a blank on how to look it up.
 
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