Question HELP!!! OPTUM - PAIN MANAGEMENT INJECTION DENIALS

aosborne88

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Glendale, AZ
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We have been having an issue of getting our pain management injections paid by Optum Lifeprint (ex. ESI, MBB, RFA, Joint, etc). Everytime we bill an injection, we get a denial stating that Optum requires a drug code to be associated with the claim. And here is the kicker: we don't buy the drugs in bulk and they are billed by the pharmacy. To avoid the pharmacy having any issues, we tried to put a miscellaneous drug code, J3490, with a zero dollar charge, but now they are denying the injection all together and only paying imaging codes. We have not been able to find any policies to explain this and Optum has been reluctant to provide one.

Has anyone else had this issue? How have you ensured payment?
 

OpenClaims

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Miami, FL
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If the pharmacy is billing the drug codes, I would think they would set up your EMR to include drug/facility charges for the same encounter on a facility claim. That is what I've always seen facility's doing and we've never had an issue with this.
 

amyjph

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Munising, MI
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If you are talking about billing for the physician (ex. physiatrist) performance of the injection, and it is being done in a facility, you shouldn't be putting any drug (J) codes on the claim at all. Your claim would have just the injection such as 644836, 64484. Drugs require NDC codes. Or, are you talking about the facility claim?
 

aosborne88

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Location
Glendale, AZ
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If you are talking about billing for the physician (ex. physiatrist) performance of the injection, and it is being done in a facility, you shouldn't be putting any drug (J) codes on the claim at all. Your claim would have just the injection such as 644836, 64484. Drugs require NDC codes. Or, are you talking about the facility claim?
These are for in office injection procedures. There is no facility charge.
 
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