Wiki Low Back Pain Diagnosis - Please Help

[tgenius1]

Patient is 62 years old referred to Physical Therapy with a diagnosis of low back pain and left ankle pain 15 minutes of Therapeutic Exercises
15 minutes of Heat/Cold Therapy
Return to Clinic in 1 week
Performed by a Physical Therapist

I coded M54.5 for the back pain and was cited incorrect then I re-coded to R52 and was cited incorrect again. I am totally confused any thoughts?

 

[daedolos]

The claim bounced back from insurance or an auditor said M54.5 is no good?

Peace
@_*
This issue might be due to your contract with the insurance. Some contracts specify not to include spinal issues.

 

[justinebaker]

Low Back Pain

Patient is 62 years old referred to Physical Therapy with a diagnosis of low back pain and left ankle pain 15 minutes of Therapeutic Exercises
15 minutes of Heat/Cold Therapy
Return to Clinic in 1 week
Performed by a Physical Therapist

I coded M54.5 for the back pain and was cited incorrect then I re-coded to R52 and was cited incorrect again. I am totally confused any thoughts?

That is a pretty common code, so I'm not sure why they would deny that. A lot of insurance companies will not pay for Heat and Ice. Which codes did you use? Which insurance company was it?

 

[daedolos]

Well, R52 is a no-no. It's unspecified. The issue I brought up was that our contract with a private insurer excludes any spinal issues so we are careful to screen patients with certain insurance accounts so as to have denied claims. Those patients can see us for other orthopaedic issues, just not spinal issues and it's only for a select set of groups. That said, you have to get the EOB or speak with a customer rep to explain why you got the denial. Also, depending on your LCD, you need to carefully select your CPT codes. Also, could there have been another error?

https://www.webpt.com/cpt-codes

Peace
@_*
Just dig deeper before resubmitting the claim. Multiple claims just muck up the process.