Post op visit addressing unrelated complaint?

ashae17

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I have an office visit (CPT 99213-24) denying as "service is inconsistent with the patient's history". The dx is cervicalgia M54.2
The patient came in for a follow up visit following carpal tunnel release procedure, and the other issue addressed was cervicalgia. For this portion of the eval, Cervical MRI was reviewed, where the only pertinent finding was "Straightening of cervical lordosis may be positional or related to diffuse muscle spasm." The doctor didn't diagnose any condition and still referred to cervicalgia in the assessment. The MDM involved activity modification and medical management, neurology referral.

It is documented throughout the report that cervicalgia was being addressed in contrast to the normal post op appointment. An appeal was submitted with denial upheld. Is there something I'm missing here? This is not a denial for E/M level, they seem to be missing the reason the established visit was billed. Is there another dx that should be primary on the charge? Z47.89 secondary? Thanks for any help.
 
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SharonCollachi

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Cervicalgia is neck pain. I find that denial reason to be odd. What was the specific reason the appeal was denied? Are they lumping it together with the post-op followup? Was the visit within the 90 day global period?
 

Orthocoderpgu

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I agree. I see no reason for a denial by the insurance. It was made clear that your physician was treating a medical condition unrelated to the prior procedure being performed. I'm assuming that this visit was within the global due to the -24 being used. If there is anyone out there who works for an insurance company can you please respond?
 

ashae17

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This was originally a post op follow up appointment, so the patient's previous incision was also reviewed in the same visit, however since the patient's neck was also addressed and was unrelated, it was billed as cpt 99213-24.
 

SharonCollachi

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This was originally a post op follow up appointment, so the patient's previous incision was also reviewed in the same visit, however since the patient's neck was also addressed and was unrelated, it was billed as cpt 99213-24.
I think that may be part of the problem. You DID see them during global for a related reason, but you also happened to throw another reason in there. Not saying it's right, just saying it's problematic and gives them a reason to deny. If you bill with the carpal tunnel dx (I'm guessing you did), AND the 24 modifier, you're telling them it's unrelated when it is clearly related to the carpal tunnel surgery, hence the "inconsistent with history" denial.
 
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I have an office visit (CPT 99213-24) denying as "service is inconsistent with the patient's history". The dx is cervicalgia M54.2
The patient came in for a follow up visit following carpal tunnel release procedure, and the other issue addressed was cervicalgia. For this portion of the eval, Cervical MRI was reviewed, where the only pertinent finding was "Straightening of cervical lordosis may be positional or related to diffuse muscle spasm." The doctor didn't diagnose any condition and still referred to cervicalgia in the assessment. The MDM involved activity modification and medical management, neurology referral.

It is documented throughout the report that cervicalgia was being addressed in contrast to the normal post op appointment. An appeal was submitted with denial upheld. Is there something I'm missing here? This is not a denial for E/M level, they seem to be missing the reason the established visit was billed. Is there another dx that should be primary on the charge? Z47.89 secondary? Thanks for any help.
I am in KY. I have solved this by billing the E/M with Correct-unrelated DX attached and also line 2 billing 99024 with the post op DX attached with $0.00 and I haven't had any issues. hope this helps.
 
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