Wiki HELP!!! Our PA charges 20610 being denied by Medicare!

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laurenortho

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Hello! Why is Medicare denying injections (20610 or 20611) that are billed under the PA (Physician Assistant). I understand that Medicare changed their guidelines in 2015 but WHY? That is the whole purpose we HAVE a PA so she can alleviate some of the work off the doctor but now she will not be paid for the work that she does. Is their a workaround? I'm adhering to the LCD guidelines and ensuring that the diagnosis is good and medically necessary per the notes. What am I doing wrong? They deny every single one as NON-COVERED and NOT medically necessary.... but it is!!!!
 
20610 vs 20611

What medication, if any are you billing with the injection? 20611 is to be billed if fluoroscopy was used. The code was changed because a lot of providers billed 20610 in conjunction w/76942, so 20611 was added in 2015 and the code description states it 'includes video fluoroscopy'. Are you billing that also?
 
reply to 20610 vs 20611

We're billing w/ different medications including J1030, J7321, etc.. It's paying for our doctors.... Just not the PA anymore and I can't seem to find any documentation WHY this changed in 2015!
 
Well to be compliant with "incident-to" - if it's a NP , then under the PA... but if it's an existing patient w/ no new problems, under the doctor..
 
I would check with Medicare as it may have something to do with credentialing for your PA.

If you refile under the Dr and they pay, then I would definitely think it has something to do w/the PA and credentialing.

Only other suggestion is based off how many injections your patient has had they may want to see medical records to proof medical necessity.

Have you added the KX modifier and refiled?
 
If the denial states Not Medically Necessary that usually means the diagnosis code you are billing with is not a covered diagnosis. I would definitely call them to get a more detailed reason as to if it is because of a diagnosis or if it has to do with the way the PA is credentialed or some other issue.
 
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