Wiki Physical Therapy - Medicaid denial

[mnk8383]

Help Please!!! We are an ortho practice who has our own physical therapy department with one MPT. We keep getting the same denial on all of our claims that are Medicaid only patients stating" Dx or Service invalid for receipient age. Verify MID, dx, procedure code/mod." When I call Medicaid I have spoke w/ 3 different rep's, telling me 3 different answers. I have been told that its a credentialing issue, that they have him listed as a provider type 9 and that I need to call provider enrollment. So when I call provider enrollment, they have no idea what Im talking about and said his credentialing looks fine. Another rep tells me that we can't bill for PT OVER the age of 21 without a modifier. I have never heard of a modifier that defines that we are treating a patient over the age of 21. I've been a coder for almost 5 years but I don't seem to be familiar with a modifier like that and I've looked at the HCPCS book up and down. I am STUCK and Medicaid is absolutely no help AT ALL. I don't know what to do. Our claim looks fine, with billing for the correct cpt's, etc. Does anyone have any suggestions???

 

[mitchellde]

Not sure, what dx are you using? For physical therapy your first listed dx must be V57.1, then the code for the reason for the therapy.

 

[mnk8383]

Well we tried that dx too. I just hung up the phone with a Medicaid supervisor who just informed me and the office manager we cannot bill for physical therapy for patients over the age of 21. This just doesn't make any sense and why wouldn't they tell us that when we had him credentialed. She mentioned billing under our physician as the supervisor but our physical therapist is the actual one who rendered the service.

 

[mitchellde]

OK then was the service provided in the office while the physician was on site? If so then you may bill under the physician if not then no.

 

[mnk8383]

Our physician is only in the office on Tues, Thurs & Fri. He is in surgery Mon & Wed. Our therapist is there Mon-Fri. Thanks for the input. We are meeting with our physician and therapist tomorrow to explain the situation. We are not going to be able to get reimbursed for the patients we have seen thus far. I am just so frustrated that we were not told this when our therapist was credentialed. Thats a huge deal to not be able to provide therapy for ages over 21, thats all of our patients...