Injection denial - UHC

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Hello,
I'm wondering if anyone can help me or give me some thoughts. I have a patient that had pes bursitis, lateral deltoid insertion tendinitis and biceps tendinitis. All on the right side. This was done in 2015 so it's ICD9. For the injections, i put 20610 RT (726.61), 20550 59 RT (726.12), and 20551 59 RT (726.19). The note specifically says that the deltoid insertion was injected which is why I used 20551 and the biceps tendon I use 20550. I wrote an appeal and sent the documentation. In the appeal I stated that they were three completely different areas/injections and that we should get payment. This 2nd level appeal I'm writing brings up the fact that the LCD list even supports the DX codes & CPT codes. It also brings up the guidelines stating that if they were into the same tendon sheath/ origin then I would only charge for one injection. These are two different ones (as if the names of both weren't enough). I just don't know if i'm missing something or what. Payer is UHC.

Thank you!
 
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Hello,
I'm wondering if anyone can help me or give me some thoughts. I have a patient that had pes bursitis, lateral deltoid insertion tendinitis and biceps tendinitis. All on the right side. This was done in 2015 so it's ICD9. For the injections, i put 20610 RT (726.61), 20550 59 RT (726.12), and 20551 59 RT (726.19). The note specifically says that the deltoid insertion was injected which is why I used 20551 and the biceps tendon I use 20550. I wrote an appeal and sent the documentation. In the appeal I stated that they were three completely different areas/injections and that we should get payment. This 2nd level appeal I'm writing brings up the fact that the LCD list even supports the DX codes & CPT codes. It also brings up the guidelines stating that if they were into the same tendon sheath/ origin then I would only charge for one injection. These are two different ones (as if the names of both weren't enough). I just don't know if i'm missing something or what. Payer is UHC.

Thank you!

Can you clarify what code(s) was/were denied and what was the denial reason? I assume 20610 and probably 20550 got paid, and 20551 was denied. What did the first appeal denial say?

I think the problem is with the DX 726.19 on 20551. I know it's intended to be for the deltoid, but it's not specific enough to separate from 726.12 (biceps). Basically what UHC is seeing is two injections happening in the shoulder; which points to their same tendon/origin means one charge guideline. (Which is applicable across the board for coding injections). I've read in multiple places that injections like this need specific diagnoses to show the separate locations.
 

smontague

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Are you contracted with UHC? If not they may be denying for out of network.

What is the actual denial reason?

Are you billing professionally or institutionally -- if it is a Medicare Advantage/Medicare replacement plan through UHC they may not cover if you are billing institutionally. I know I work for an FQHC and we now have to bill using the Medicare PPS codes (g-codes) and these types of procedures are not considered "qualifying visits" -- not sure if maybe this applies to you as well, depending on the type of facility you work for.
 
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I'm in a doctor's office. 20550 and 20551 both got denied. We are contracted through UHC, and it's not a Medicare replacement plan or anything. Is there a better diagnosis code you could suggest for the deltoid? They're two different muscles/tendons, two different DX. But I don't know if there's a better DX code for the deltoid tendinitis or what. And my appeal clearly stated that they're different. I THINK we should get paid for all three but I just want to know and understand what I need to do to get payment.

Denial reason: HR:Charges were reconsidered and the claim was processed per member benefits, as a result of the additional information provided
AU: The CPT, HCPCS, or revenue code billed is incorrect. Please submit a corrected claim with the appropriate code. If you believe the code you submitted is valid for the date of service and correctly identifies the service rendered, you may submit an appeal with the medical record documentation and the rationale for the code as billed.
 
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