IUD placement failed in office, moved to OR with anesthesia. Tricare denying. 58300 CPT Code

[aannecchiarico]

Patient was seen in office to have IUD inserted but could not tolerate procedure. Patient was then placed under anesthesia at the hospital on same campus where the IUD was inserted successfully.

Tricare is denying claim for "SERVICE ON SAME DAY AS AN EDIT DENIAL WHICH CAUSES ALL OTHER SERVICES TO BE DENIED". Called Tricare and they stated that

1. There is no primary procedure code on the claim which could be causing an issue. (58300 is on the claim and should be the primary procedure.)
2. There is already a $650.00 claim for anesthesia that was already paid for the same date of service. (This is the anesthesiologist billing for their services.)

He suggested to try to send medical records with the claim to prove medical necessity.

CPTs billed are 81025 / 58300 / J1596 JZ / J1885 JZ / J2250 / J2704 / J2704 JW / J3010 / J3010 / J7120

There is also a PB claim that was billed by the physician and paid by Tricare for the CPT code 58300 on the same date of service.

My manager and I are wondering if this coding is correct and how to get this HB claim paid by Tricare. Should the provider not have billed for the 58300 as well?

Thanks in advance!

 

[vsmith154]

Hi,
I am not real familiar with Tricare billing; but when we have IUD insert failures......we bill the attempted insertion with a modifier 53. This usually happens if we have a mid-level who cannot insert. When the patient returns to see the physician, we bill normally and are paid for both. Of course, include your documentation.

Hope this helps.