99406 denial for medicare

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Good Morning, I work for an urgent care the doctor always bill 99213 and 99406 together and Medicare always deny the claim stating they can't be billed together. Can someone please help me. Thanks
 

TThivierge

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Lithonia, GA
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Denial of CPT 99406 Weight Smoking Behavior Change Visits and office visit

Hi M

The insurance denial could be does the notation of the provider for the day reflect 2 diagnosis problems? Are the CPT codes linked to the proper dx codes? .For instance let us say the patient has HNT and CKD but doc is also monitor their BMI weight issue . The documentation MUST reflect the patient's problems and the weight problem. Are the dx codes Z71.3 weight management linked to 99406, plus adding a modifier 25 to the Eval Mgmt office visit. The BMI and E66 dx codes should be on the same claim but also the BMI % of the patient's should be noted in the medical record. And if the patient has BMI less than 30% it will not be covered...CMS regulation per the LCD info. If the patient has Medicare funding make sure use the proper G codes.

Also you can check the payer's billing regulations because it may need pre-authorization and most payers only covers 6 weight management sessions a year.

Ok I hope this information helps you:)

Lady T
 

Urvishah

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99406- smoking cessation >3 min. Medicare denied

Hi,

Medicare denied all 99406 ( Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) codes with my e/m code. I stated the diagnosis code
F17.200 - (Nicotine dependence, unspecified, uncomplicated) also with it and with 25 modifier. Please help me on it.

Thanks
 

cgaston

Expert
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Medicare will only pay a total of 8 cessation counseling codes (99406 or 99407) per year; not per provider. If other providers have also billed for cessation your patient could have hit the maximum for the year.
 

Urvishah

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99406- smoking cessation >3 min. Medicare denied

Medicare will only pay a total of 8 cessation counseling codes (99406 or 99407) per year; not per provider. If other providers have also billed for cessation your patient could have hit the maximum for the year.
I am working in Pain management , so Medicare didn't allow 99406 with office visit? Does it comes under regular physicians office visit?
 
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Medicare will only pay a total of 8 cessation counseling codes (99406 or 99407) per year; not per provider. If other providers have also billed for cessation your patient could have hit the maximum for the year.
Do you just have to assume the patient has hit their maximum because it gets denied with an appropriate diagnosis code?
 
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"These are time-based codes and time spent with the patient must be documented in the medical record. When documentation supports that a significant, separately identifiable problem-oriented evaluation and management (E/M) service is rendered, the appropriate code for the E/M service may be reported separately. Append modifier 25 to the service code selected to indicate that a separately identifiable E/M service was provided on the same date of service as the counseling service." this notation came from my coding software. So, it looks like you need to add modifier 25
 

Urvishah

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99406- smoking cessation >3 min. Medicare denied

"These are time-based codes and time spent with the patient must be documented in the medical record. When documentation supports that a significant, separately identifiable problem-oriented evaluation and management (E/M) service is rendered, the appropriate code for the E/M service may be reported separately. Append modifier 25 to the service code selected to indicate that a separately identifiable E/M service was provided on the same date of service as the counseling service." this notation came from my coding software. So, it looks like you need to add modifier 25
My provider states that "Smoking cessation discussed with patient > 3 minutes", and I added 25 modifier too, and also checked that patient finished only 3 smoking cessation so still 5 cessions are remaining
Then also Medicare denies all 99406, any more clarification please!

Thank you.
 

Agilbert3

Networker
Local Chapter Officer
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Same issue

Our clinic also received denials for 99406 with F17.200. Look at NCD 210.41 in the Medicare Learning Network and you will see Medicare has very specific ICD codes to allow payment of this service.

We started documenting the type of tobacco product used since Medicare does not accept F17.200-F17.209.

We are not sure why they don't accept them since they iterate that they will cover patients who " Use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease. "

Alas, going forward we will be prepared.
 
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