Assistance -78452

[fred1994]

Does anyone have advice on 78452 and using codes A9500 and A9505? I work in a cardiology office and CareSource is stating that A9500 and A9505 is included in the payment for the 78452. Based upon I have found this is not the case.

 

[trarut]

Because it's CareSource and they apparently can. They started bundling isotopes/contrast/etc into the reimbursement for the imaging exams several years ago based on my experience with them. We fought it constantly at my last job but never won. They wouldn't budge. Their rationale seems to come down to "you can't do the test without it so it's bundled" or that the test description states "with contrast" in some form.

I'd love to know if anyone has successfully argued this and gotten it turned around. It may be worth it to address at the next contract negotiation if it's a big enough issue for your organization.

 

[thomas7331]

Bundling rules are a matter of payer reimbursement policy, so can vary from one payer to the next. Although Medicare and payers that follow NCCI do not include the costs of A9500/A9505 into their payment rate for 78452, apparently CareSource does. If your provider is contracted with them, then you've likely agreed to accept those rates and bundling policies in the contract, and there's not much you can do. I agree with the last post - if you find that the rate they pay for 78452 doesn't cover your costs for the procedure they're denying, then you should definitely bring this to your network representative's attention and address this the next time the contract is up for negotiation, or advise CareSource that you can't continue providing that service for their members as it is causing you a loss in revenue.

 

[holbjm@hotmail.com]

Have you tried adding a 59 modifier? I know Molina Medicaid requires prior auth on isotopes maybe CareSource is following ?