Wiki How to Educate Provider to Not Bill a Deleted Code

[khartoum1900nile@aol.com]

I have a pediatric therapist, who is also the owner of the office, who thinks it is okay to bill deleted codes to insurance. I recently stepped into the role of biller for the office and now I'm in a dilemma. The therapists have been billing a deleted code for I don't know how long and I don't know how the previous biller handled this, mostly due to lack of detailed notes and working remotely in another state.

When I came across this deleted code and saw that the replacement code should be used instead, I got blowback for this. The owner stated that they use the deleted code because they have been getting paid for it by Medicaid. The owner said they used the replacement code one time and stopped because Medicaid didn't reimburse for the services rendered. I was told that the therapists will use the replacement code for one claim submission and if it doesn't pay, they will go back to using the deleted code. The owner even told me that she couldn't find any online resources to support the use of the replacement code over the deleted code. I told her that I looked it up in my CPT book, but that wasn't enough to convince her.

I would love to continue working in billing, but I'm just done trying to help providers when they are so hard-headed. I don't know what else to do, except move on from this position and let the office go back to their old ways and have the money recouped down the road.

 

[catherinetinkey@entmedicalservices.org]

There are a couple things you can do, first like you said just because something gets paid does not mean it is the correct thing to do. Eventually it will all be recouped and you may not get to submit a different code due to timely filing. What are the two codes in question? When did the delete become effective? Check your Medicaid fee schedule see if the code has been deleted from it.

 

[khartoum1900nile@aol.com]

The deleted code is 97762 (Checkout for orthotic/prosthetic use, established patient, each 15 minutes) and it was deleted in 2018. The replacement code is 97763 (Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes). Both codes are not listed on the Medicaid Fee Schedule. However, 97762 is still listed in Chapter 37 of the Medicaid Manual.

 

[catherinetinkey@entmedicalservices.org]

Are they billing the new code for initial encounters? It can only be use on subsequent encounters.

• CPT 97762 was deleted: 1/1/2018
  This code is no longer valid for billing purposes.
  
  
• • CPT 97763 is the replacement:
    It is used for subsequent encounters for orthotic and prosthetic management and training.
    
  • 97760 and 97761 were updated:
    The descriptors for these codes were amended to specify "initial encounter," focusing them on the initial assessment and fitting of orthotics and prosthetics.