Wiki Injections- code for an urgent

Create Wiki
A

Anon

Guest
Messages
4
Best answers
0
I code for an urgent care facility. We seem to be getting denials when an injection code is used. The most recent one has been Tricare, but United Health Care has done something similar, which was fixed with a modifier.

We billed the following to Tricare:
99204
S9088
96372
J1030
J1040

They didn't pay anything for the E/M or S code. The rational for the E/M code was: "Medical visit included in allowance for surgical or medical treatment according to Tricare claim check".

Are they bundling codes? Do I need a modifier? Thanks for your help.
 
Our provider is a neurologist who seems patients for acute care in his office. We too, have similar issues and usually have to send in chart notes even though the original claim had modifer appended to the office visit. We've discovered that if criteria and documentation have been met, most of the time the denials for the bundling issues overturn, especially for Tri-care patients. We'll appeal these bundling denials by mailing the notes to the Claims Check address as instructed by customer service. It's tedious task, but it's worked for us. And yes, in our case we do use modifier 25.
---Suzanne E. Byrum
 
You can also submit Claim check appeals online for tricare. Much easier then mailing all that mess off and faster turnaround.
 
I work for a payor and yes the modifier-25 is needed for the office visit. The S9088 and similiar temp codes are hardly ever reimbursed since it is indicating that the member presented to a UC and its a "given", therefore is usually considered redundent. But you never know till you bill right? ;)
 
You must log in or register to reply here.
Top