Age guideline 73520

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jgf-CPC

jgf-CPC

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:confused:Does anyone know the AMA age guidelines for the difference in the 73520 and 73540? We had a denial from Wellcare and were told that the AMA limit on the 73520 was 12 years and older. Where would I find a link to find the answer to this and thanks so much for any help I can get
 
Wow that is shocking to me. At our office we use a book called the CSI Navigator and there is a section that states "most payors consider an infant to be less than one year of age", so that is what we go by when using the infant xray codes. I work denials in our office and had one returned that an infant upper extremity code was used on an 18 month old and they denied for age appropriate CPT, so we refiled with the forearm and humerus codes and it got paid. But I have never heard of the AMA having that rule on xrays and I can't find it anywhere in the CPT book or online. As far as I know we only have those few age specific "infant" ones and those are for the babies. I always use the rest for age 1 year 1 day and older and have never had a problem.

Good Luck, it seems like Wellcare is just being subborn.
 
Thanks Audra but I think I have confused you. The 73540 is the infant or child. The 73520 we felt was for any age above that but not 12 years and above!!! If anyone can explain this please do!
 
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How old is the patient?

Jackie,
How old is the patient?

Radiology is NOT my area of expertise, but I think the problem is that 73540 says "infant or child" (emphasis added by FTB)

But I don't find a definition of "child" anywhere in CPT. The closest I can come is under the Pediatric Critical Care codes which end at age 6. (i.e. age 6 and older uses the regular Critical Care codes)

I've seen 10-year-olds who are bigger than their parents, so I would wonder how the payer came up with the decision that 73520 starts at age 12?

Hope that helps somehow.

F Tessa Bartels, CPC, CEMC
 
He was 9 and the payor said 12 and up was the 73520 so we did end up changing it to the 73540 to see what they do with that. I feel that it is for younger children since it says infant or child. They had stated when we called them on the denial that the AMA used that guideline for 12 years and older on the 73520 but that was all they would tell us. Thanks for your help! Hope someone else has heard this before????:confused:
 
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