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Rachel.wimb@gmail.com

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Morning everyone,
I have taken over billing and I have several rejections im looking at. one in particular remarks are stating inconsistent with billing guidelines regarding the line info. I see it is billed for 72050, 72100, 98941, 99204. I have the mod 25 and AT on correct codes. im thinking its the primary dx and dx pointers. current primary dx is r29.3. after checking the notes this pat came in with many previous conditions and one of those were m47.812 and m47.816. I think the dx is just a symptom and could be more specific. can i get help on this?
 
98941 bundles with the E&M code, so sometimes even with the -25 they're only going to pay the chiropractic. 98941 inherently includes some elements of evaluation and management within the code's work RVUs, so they don't generally pay both. You're right.... R29.3 is the symptom code for abnormal posture. That's not going to show medical necessity for a chiropractic maneuver. In order to report chiropractic services, you're better off if your provider gives you a specific condition (which he should be able to determine based on reading the films). Even though M47.812 and M47.816 are previously reported, it would be up to the provider to validate those diagnosis codes for his own procedures. Involve your provider with the denial management process, and let him/her know that a medically necessary diagnosis is going to be extremely important if he/she wants to get paid.

It might be helpful to do some research on coverage policies for all of your common payers. Figure out what they will cover and for what condition. Use this as an educational tool for your provider(s). Good luck! :)
 
Pam Warren said:
98941 bundles with the E&M code, so sometimes even with the -25 they're only going to pay the chiropractic. 98941 inherently includes some elements of evaluation and management within the code's work RVUs, so they don't generally pay both. You're right.... R29.3 is the symptom code for abnormal posture. That's not going to show medical necessity for a chiropractic maneuver. In order to report chiropractic services, you're better off if your provider gives you a specific condition (which he should be able to determine based on reading the films). Even though M47.812 and M47.816 are previously reported, it would be up to the provider to validate those diagnosis codes for his own procedures. Involve your provider with the denial management process, and let him/her know that a medically necessary diagnosis is going to be extremely important if he/she wants to get paid.

It might be helpful to do some research on coverage policies for all of your common payers. Figure out what they will cover and for what condition. Use this as an educational tool for your provider(s). Good luck! :)
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Hello again, I wanted to update you on this, and I can happily say that was a factor. we have changed the primary dx to m99.03, I believe it was, although it did not pay the office visit, at least the 98941 has started paying! Would you be able to help me with another issue? its regarding payer rejections.: CPT codes 99204 mod 25, 73565, 20610 mod LT, J0665, J2001, J1885. My provider mixed these and only administered one injection.
 
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Even with a new patient visit, CCI does bundle E&M into procedures like the 20610, even with a -25 modifier, some payers won't reimburse separately. CPT 73656 is an upright standing film of the knees; I'm assuming that if you're billing it globally, the provider is also documenting a formal read (a wet read is not sufficient). And that you own the xray equipment (if not, bill with a -26 if he only does the read). In terms of the drugs: J2001 is for intravenous lidocaine. You did not do an IV injection; you did a therapeutic injection, so scrub that right off the claim. Additionally, because bupivicaine is also an anesthetic, your payer may bundle that into the ketorolac; the 'caine' medications are often not separately reportable with procedures since they're considered the anesthetic necessary to perform the procedure, but you can try.Lidocaine is never separately billable; it's inclusive to the procedure. They'll adjudicate it (probably) as provider responsibility. How many units of ketorolac did he administer? It's billable by 15 mg. units, so if he administered 45 mg., you'd report 3 units. Hope this helps.
 
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