We bill 20610 all the time to Humana and Medicare with many different Dx codes but all of a sudden Humana is denying then when billed with dx M67.811 and all the other codes in that dx family. I have checked the CMs website and there isn't a LCD code listing for this cpt. Can any one help me?? Have called Humana but I find whenever I call them it is a waste of my time and don't get clear information that makes any sense.
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Wiki Humana is denying my cpt 20610
- Thread starter Denise Langford
- Start date
daedolos
Expert
Check the details of the claim. Is there perhaps a discrepancy with the laterality of the modifier for 20610?
Peace
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hamlinr2005
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I checked with coder and for diagnosis code M67.811 it does not have 20610 as an appropriate CPT crosswalk. It is stating that for that diagnosis code, the injections that are covered are:
20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")
20551 Injection(s); single tendon origin/insertion
20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s).
Since 20610 states it is for the joint/bursa, I bet the insurance is not including a synovial problem as a reason to do this injection. Hope this helps!
20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")
20551 Injection(s); single tendon origin/insertion
20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s).
Since 20610 states it is for the joint/bursa, I bet the insurance is not including a synovial problem as a reason to do this injection. Hope this helps!
AlanPechacek
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M67.811 is from the Code Set M67: "Other" Disorders of the Synovium and Tendon. "Other" usually seems to mean "none of the above" and therefore is very nonspecific as a diagnosis code. M67.811 revers specifically to a "disorder" of the synovium of the right shoulder. This Code Set is really very vague ("non-specific") and almost meaningless as a diagnosis, which may be the problem with getting approval/compensation for 20610, Injection Major Joint or Bursa, when the two are submitted together. I think you need a much more specific diagnosis in order for the two of them to work. As it regards the shoulder in particular, I would try to get one from the M75 Code Set for Shoulder Lesions, if possible. If not there, then from M65: Synovitis and Tenosynovitis, from which there is M65.81_ for "Other" Synovitis and Tenosynovitis of the Shoulder, but again not as specific as you would like. If the shoulder problem is "Work Related" and from Use, Overuse, and Pressure, then one M75.81_ might apply, but unfortunately this is another "Other." The M75 Code Set is the most "specific" for Shoulder Problems.
Hopefully this helps you. I would refer you to my Blog regarding coding shoulder pain at icd10orthocoder.com, where I have tried to sort this out.
Respectfully submitted, Alan Pechacek, M.D.
Hopefully this helps you. I would refer you to my Blog regarding coding shoulder pain at icd10orthocoder.com, where I have tried to sort this out.
Respectfully submitted, Alan Pechacek, M.D.
KMCFADYEN
Expert
Denise,
first of all, I do not care for Humana.
they tend to make it more difficult to get claims paid.
But, in this case, I think your problem is either an incorrect CPT or ICD-10.
Check the documentation for what was actually injected and make sure the diagnosis is accurate.
M67.811 does not support medical necessity for CPT 20610
first of all, I do not care for Humana.
they tend to make it more difficult to get claims paid.
But, in this case, I think your problem is either an incorrect CPT or ICD-10.
Check the documentation for what was actually injected and make sure the diagnosis is accurate.
M67.811 does not support medical necessity for CPT 20610
DHouseholder
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Our office is also receiving denials on 20610 on a variety of diagnosis codes that were previously paid. I just received a response from the Humana Code Editing Team per my request for review and the response was they are imposing LCD L34284 from another jurisdiction (Cahaba JJ) which is for TN, GA and AL....we are located in NC (Palmetto JM) and there is No LCD for this code in our area. It was also stated that due to their is no NCD for this code this allows Humana to impose this LCD on our claims with this code.
I just called the Humana Provider Relations Dept. at 800-626-2741 and spoke with a Rep. who stated they should be following Medicare guidelines per "our jurisdiction and per our Contract" so he is sending this to be reviewed by a Marketing Contractor Rep. who will eventually respond with the outcome of his/her review.
When/if I get a reply from the new review I will post their response.
I just called the Humana Provider Relations Dept. at 800-626-2741 and spoke with a Rep. who stated they should be following Medicare guidelines per "our jurisdiction and per our Contract" so he is sending this to be reviewed by a Marketing Contractor Rep. who will eventually respond with the outcome of his/her review.
When/if I get a reply from the new review I will post their response.