Wiki Emergency room follow up

[sarame]

We have a patient who was in the ER for a episode due to his pacemaker. He left the ER and came right to our office stating he had a cold and wanted to be treated. We billed for the OV but Medicare denied it as non-reimbursable. Is there a modifier I can use? Would a 25 work? Thanks!

 

[mitchellde]

What dx code did you use? Since an ov for symptoms is always covered

 

[sarame]

a 99213 was used, Medicare paid and offset on the same check. Denied nonreimbursable J1. I believe that is the reason.

 

[mitchellde]

Was your provider the one that billed the ER visit ?

 

[sarame]

My provider was not part of the ER. I am however even more confused because I received another denial for the same patient seen again a few days later. It is a J1-nonreimbursable adjustment code. Medicare is paying but offsetting on the same RA????? Is anyone familiar with this code??

 

[mitchellde]

What were all the codes used on the claim.

 

[sarame]

99213

 

[mitchellde]

My provider was not part of the ER. I am however even more confused because I received another denial for the same patient seen again a few days later. It is a J1-nonreimbursable adjustment code. Medicare is paying but offsetting on the same RA????? Is anyone familiar with this code??

Here is interesting info I found on the J1 adjustment code
Non-Reimbursable (J1)

Adjustment Code Reference ID
Non-Reimbursable (J1)

Used when the service provider is also the employer group and they request that monies be applied towards the Group Medical Plan coverage premium instead of the claim
The Reference ID in the PLB J1 contains the comment "Suppressed Payment Arrangement".
Posting Tips

J1 will be in the same 835 as the claim.
Post amounts to your patient accounts, but note that you will not physically receive funds for the claim payments.
The dollar amount of the suppressed payment for the PLB J1 will be a positive value.

 

[sarame]

I found that also, however none of this rings true for our provider or patient. I will have to call Medicare to solve the puzzle. Thanks!