Wiki Denial by secondary insurance - HELP!!

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crhunt78

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Hello. I have a situation where one of our psych docs saw a patient at a Comprehensive Inpatient Rehabilitation facility (POS 61). The patient was elderly and had Medicare as primary insurance so our physician billed a 99223 instead of a consult code which is perfectly acceptable for Medicare purposes. Medicare, as the primary insurer, paid their part of the claim, however, when the claim was sent to the patient's secondary insurance, Magellan - Cigna's behavioral health plan, it was denied because they say that CPT code 99223 cannot be billed in POS 61.

Does anyone know what we should do with this secondary denial? Magellan wants us to use a CPT code from the range 99304 - 99310 (Initial/Subsequent Nursing Facility Care) but we don't think we should have to change the CPT code based on a secondary insurance denial because Medicare already paid.

Did we code this wrong in the first place? Should we have billed Medicare using 99304-99310 or were we correct in utilizing the consult crosswalk and billing the 99223? Has anyone else had this situation arise? Any help you can give me would be greatly appreciated!

:confused::confused::confused:
 
Pos

I would tend to agree with Cigna. We don't do a lot of hospital billing, but I would think the 99221-99233 would only be paired with POS 21. I'm surprised Medicare paid that combo. Maybe there is something to this that I don't know. Where did you get the crosswalk?
 
The crosswalk is something that we've used since Medicare quit accepting consult codes. If a physician does a consult and the patient has Medicare, based on the key components of an E/M, we crosswalk their consult level of service to an initial inpatient code.

I agree that maybe Medicare incorrectly paid. This is the first time we've had this problem though. Since the physician who saw the patient is a psych doc then maybe she should have billed the psychiatric diagnostic CPT code instead of an E/M service. What are your thoughts on that?
 
why didn't you use psych codes? they can be used in any place of service. the initial inpatient codes are to be use in an acute care inpatient setting, psych rehab is not an acute inpatient
 
The doc is the one who coded it. Unfortunately, it didn't come to me until after it was denied by the secondary insurance. I know that psych rehab is not an acute inpatient POS and I wouldn't have coded it that way. What I'm asking is now that it is being denied, does anyone have any suggestions? Should we refund Medicare and bill it as an initial rehab code or should we refund and bill as a psych initial diagnostic code?
 
I was always told (and I don't have any resources to back this up, hopefully someone with more experience will chime in), that once a claim is processed by any federal payer, you cannot make any changes to it for a secondary payer unless you refile the claim to the federal payer also. So in the question above, in order to change to the psych codes, Medicare would have to be refunded, and the entire claim corrected. Anyone have any thoughts on this?
 
refund

I agree the claim needs to be corrected with Medicare first. It depends on your local carrier how you fix it. We can change some info over the phone with a re-opening of the claim and once it is reprocessed they will request what is owed to them.

Or you can send a voluntary refund of the whole payment amount and state it was billed in error. After the refund is processed you can file a new claim. Hope that helps.
 
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