Need Appeal Help for denial of injections with office visit


True Blue
Everett, WA
Best answers
We have a well-known carrier in Nevada (follows MCR guidelines)that continues to deny our appeals for injections but will pay for the office visit. Patient is seen by specialist for treatment of cervical dystonia in office for acute care and only one diagnosis is listed. It is billed out as an office visit with modifier 25 along with separate listed injections with modifier 59 ie: 99213-25, 96372, 96372-59, 96372-59 etc. with accompanying J jodes to match. We get the denial letter based on the fact that only one diagnosis has been submitted, so we argue based that two diagnoses are not always necessary. Chart notes are furnished for medical necessity. Patient sometimes ends up in the office several times per week requiring injections or infusions (after determination by PE) so patient is not presenting themselves for scheduled treatment. Our specialist provider gets nothing for the 96372 CPT codes. Personally do not want to see this go to write/off and after this second denial am turning to the list to see if we might be missing something. We've successfully appealed other denials from other carriers (including MCR), but this particular one fails to budge. Perhaps it's time to get someone to help us with negotiating a new contract? But before taking that step, perhaps some one experienced with the appeal process for this type of issue can offer advice? ---Suzanne E. Byrum CPC