Wiki Notification of Pregnancy denials

[nlynn112211]

Hello,

I work in Indiana. Only Medicaid Managed Care plans pay for the Notification of Pregnancy (CPT code 99354). Sometimes the patient will have a primary Commerical insurance and a Medicaid Managed Care as secondary. For Commercial payers we bill prenatal visits as a global package meaning we do not bill for the office visit. This is causing denials for the Notification of Pregnancy from the primary and the Medicaid Managed Care plan is denying as well.

Does anyone know of a way to better fight these denials?

Thank you for any help!

-Chantel

 

[SharonCollachi]

Let's start with the cpt code. 99354 is not "notification of pregnancy", it is Prolonged E&M beyond the typical service time of the primary procedure, first hour. So if 30-74 minutes BEYOND the usual time associated with the E&M code are spent ON THE SAME DAY WITH THE PATIENT, then you code 99354. If less than 30 minutes beyond the E&M time is spent, you code no additional time.

Whatever this "notification of pregnancy" is (calling the patient, etc.) - is it taking a full 30 minutes the same day as the E&M office visit???? For example, if there is a 99213 office visit, which carries a typical time of 15 minutes, are you spending AN ADDITIONAL 30 minutes after that on this "notification of pregnancy"?

If the additional time is not face to face with the patient, then the code is 99358.

Now, if it is indeed a valid charge for whatever is being performed, if the primary denies it, then you get no payment. You have the follow the rules of the primary.

 

[nlynn112211]

Billing for Submitted Notifications of Pregnancy For NOP claims, bill using CPT code 99354 with modifier TH:  99354 – Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service, first hour (list separately)  TH – Obstetrical treatment/services, prenatal or postpartum The date of service on the NOP claim should be the date the provider completed the risk assessment during a visit with the pregnant woman. NOP claims should be submitted to the appropriate managed care entity. Physicians can submit claims for NOP reimbursement using the CMS-1500 claim form or the 837P electronic transaction. Hospitals can submit claims for NOP reimbursement using the UB-04 claim form or the 837I electronic transaction. NOP claims from hospitals must be coded with revenue code 960 – Professional fees– General, in addition to CPT code 99354 with modifier TH.

Thank you for your reply. It is a valid charge and yes, I know 99354 is a prolonged services code but it is also used as the NOP code. I was trying to see if anyone else from Indiana was experiencing a similar issue.