Wiki Q4010

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KatieV7

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I work for orthopedic hand specialists and we have been billing Q4010 for our cast supplies for as long as I can remember and have never had any issues. All of a sudden (seems like around the first of the year) it is denying by multiple payers saying it's part of the surgical package or bundled. Has anyone else had this issue? Do I need to start using a modifier of some kind? I've called a couple of the payers and they tell me that cant tell me how to code and that they are unaware of any policy changes but to check the provider manual, ugh. Any and all information is appreciated. Thank you in advance!
 
What payers? If identified as only a single payer, do they have a claim system error that is possibly incorrectly denying these that is known and announced?
How many claims/services are denied in comparison to the volume billed?
Has anyone in the RCM quantified the time frame and first claim date of service that this was found on?
What other procedures or services were billed on the same date of service/claim?
What are the specific reason codes?
Is there something bumping up against a facility payment rate at all? Is this being done in the office POS or ASC?
Do you have a new coder possibly and maybe they are using the wrong Q code for the age or type of casting?

It is good to have data analytics and reporting if you are seeing a trend to determine the scope if you can't easily figure it out.
 
amyjph said:
What payers? If identified as only a single payer, do they have a claim system error that is possibly incorrectly denying these that is known and announced?
How many claims/services are denied in comparison to the volume billed?
Has anyone in the RCM quantified the time frame and first claim date of service that this was found on?
What other procedures or services were billed on the same date of service/claim?
What are the specific reason codes?
Is there something bumping up against a facility payment rate at all? Is this being done in the office POS or ASC?
Do you have a new coder possibly and maybe they are using the wrong Q code for the age or type of casting?

It is good to have data analytics and reporting if you are seeing a trend to determine the scope if you can't easily figure it out.
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Meridian is our main issue, but like I said, its been multiple (a few random). I tried to tell Meridian that it has to be an internal system error but they couldn't tell me that it is or direct me to where I would find that info. They told me I just have to appeal them all.
Do you happen to know were I would find this info, or do you know how to start an investigation into something like that?

We are doing everything correct. We have no new coders. We are a small practice so its just two of us and we've both been doing this for years. Nothing has changed on our end. They are denying 100% of them. Doesn't matter what other codes are on claim or if it is/isn't within a global or not. For example: 99203-pd, 29075-pd, Q4010- denied OR 26600-pd, Q4010-denied OR 29075-pd, Q4010- denied. They are all POS 11.

We had a similar situation last year with Priority Health, but their denial simply stated an anatomical modifier was needed after fighting it a few times (silly rule) we now just play their game and they all get paid.
Meridians denial says: This procedure is not paid separately. These services are not covered when performed within the global period of another service. It's a supply; this denial makes zero sense to me.


Also- I see you're from Munising. I used to live there too! Small world.
 
Have you tried calling your provider representative? https://www.mimeridian.com/providers/join-our-network/service-area.html or https://www.mimeridian.com/providers/resources/provider-relations-intake-form.html
Also, sometimes when I have had issues like this, I have contacted the member to call their insurance and complain that their claims are not being paid correctly. That has worked for me.
It sounds like this policy is being taken out of context. https://www.mimeridian.com/content/dam/centene/policies/payment-policies/CC.PP.032.pdf

If NCCI is being cited, you can throw the NCCI manual back at them.
G. Fractures, Dislocations, and Casting/Splinting/Strapping

If closed treatment or a definitive procedure was being performed, you couldn't take credit for the casting or splinting code (2XXXX), but the supplies (Q) are always paid separately. They are not included.

CMS Article example: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52767
"The splints and cast Q codes are considered Level II codes and to be used when supplies are indicated for cast and splint purposes. The payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast."

This is where issues are located: https://www.mimeridian.com/providers/claims-alerts.html
"If you have a claim that should be included in one of the claim projects below (which you believe denied incorrectly) and it has not yet been adjusted, please let us know the claim number so that we can research it and confirm. You may email us or contact your Provider Relations Rep."

Oh wow, small world! Not a common place people know lol.
 
We are seeing it with BCBS, Aetna, and Cigna now. No changes. No coder/coding changes. All scenarios are denying. Ins reps are telling me to appeal. I have sent to provider reps but that is a joke and more than likely will not get any responses or solutions. Practice is in MO.
 
Do any of your providers belong to AAOS, ASSH, AANS or any of the other specialty societies with contacts there? It sounds like this is more widespread. What years are the claims from? Is it only 2024 year?
Have you checked provider newsletters, bulletins, and claim issue alerts for these payers?
Instead of going to the customer service claims people, I would go to my provider representatives. I don't work on the provider side anymore so I don't have current info on it.
If you are ortho, I would suggest also reaching out to KZA if you have contacts there or have interacted to see what they have heard or seen. The orthopedic coding conferences are/will be going on so they may have info on this from across the country.

Are they paying everything except the Q code? Or, are they denying the casting also and due to that, then also denying the Q code?

If this is across so many payers and states, there had to be a change or something like a modifier required or they are all taking a policy out of context. I would suggest our RCM data analytics or management running reports to quantify the scope of it.

Have you read the "fracture care" policies for the payers in question? This is where you can find the casting info sometimes.
Example: https://www.bluecrossmn.com/sites/default/files/DAM/2023-07/medicare-si-006-fracture-care.pdf
Supplies No additional reimbursement will be made for surgical trays, surgical or other miscellaneous supply codes A4550, A4649, and 99070. The allowance for these codes is considered bundled into payment for the other services rendered. If the cast, splint, or strapping is applied in the office, supplies may be billed separately with the appropriate HCPCS codes (Q4001-Q4051). Cast, splint, and strapping supplies provided in a facility place of service are not reimbursable as they are considered to be included in the facility’s reimbursement for services provided. Other supplies used in the office place of service are generally considered incidental or bundled into payment for any other service performed.
 
So far all of our affected claims are 2024. I had another new one this AM, Humana Military. I've spent my entire morning searching newsletters, bulletins, claim issue alerts, & fracture care policies for many diff payers and still cant find anything, anywhere. I've left messages with provider reps with no luck on a return call yet.
My providers are AAOS members, I'll try that route. Unfortunately, I know they wont want to pay to consult with KZA. I'm determined to figure this out though! Thanks for all the input and ideas!

shortee3810-​

I saw your other post. You're having the same issues, with which payers?
 
amyjph said:
Do any of your providers belong to AAOS, ASSH, AANS or any of the other specialty societies with contacts there? It sounds like this is more widespread. What years are the claims from? Is it only 2024 year?
Have you checked provider newsletters, bulletins, and claim issue alerts for these payers?
Instead of going to the customer service claims people, I would go to my provider representatives. I don't work on the provider side anymore so I don't have current info on it.
If you are ortho, I would suggest also reaching out to KZA if you have contacts there or have interacted to see what they have heard or seen. The orthopedic coding conferences are/will be going on so they may have info on this from across the country.

Are they paying everything except the Q code? Or, are they denying the casting also and due to that, then also denying the Q code?

If this is across so many payers and states, there had to be a change or something like a modifier required or they are all taking a policy out of context. I would suggest our RCM data analytics or management running reports to quantify the scope of it.

Have you read the "fracture care" policies for the payers in question? This is where you can find the casting info sometimes.
Example: https://www.bluecrossmn.com/sites/default/files/DAM/2023-07/medicare-si-006-fracture-care.pdf
Supplies No additional reimbursement will be made for surgical trays, surgical or other miscellaneous supply codes A4550, A4649, and 99070. The allowance for these codes is considered bundled into payment for the other services rendered. If the cast, splint, or strapping is applied in the office, supplies may be billed separately with the appropriate HCPCS codes (Q4001-Q4051). Cast, splint, and strapping supplies provided in a facility place of service are not reimbursable as they are considered to be included in the facility’s reimbursement for services provided. Other supplies used in the office place of service are generally considered incidental or bundled into payment for any other service performed.
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I have checked everywhere along with others in my office. We have already engaged our provider reps but that is typically no help, at least in our area.

Docs know about it but I doubt it is very high priority for them as it is not a huge income in our practice. I still want to figure it out though as I am the one mainly dealing with the denials.

Just the Q code is denying and my payers say it is bundled in with the cast application code. also our 2024 claims.
 
KatieV7 said:
So far all of our affected claims are 2024. I had another new one this AM, Humana Military. I've spent my entire morning searching newsletters, bulletins, claim issue alerts, & fracture care policies for many diff payers and still cant find anything, anywhere. I've left messages with provider reps with no luck on a return call yet.
My providers are AAOS members, I'll try that route. Unfortunately, I know they wont want to pay to consult with KZA. I'm determined to figure this out though! Thanks for all the input and ideas!

shortee3810-​

I saw your other post. You're having the same issues, with which payers?
Click to expand...
Have you been able to figure anything out yet? We are having the same issue with Anthem, Cigna, Humana, MA NHP, and Tricare. Any insight would be helpful :)
 
Cassi3434 said:
Have you been able to figure anything out yet? We are having the same issue with Anthem, Cigna, Humana, MA NHP, and Tricare. Any insight would be helpful :)
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Nothing yet. I finally have a provider rep looking into it for me though. She has been really helpful and seems to really want to get to the bottom of it. Its starting to sound like there must have been some sort of change to the rule as it is affecting so many different payers nation wide. I will definitely let you all know what I find out. I did try appealing some of them and they came back paid so that's a good sign. However, not ideal to have to appeal them all, all the time.
 
Have any of you checked the AAPC facebook group? May be something in there too.
Interested to see what's up when you guys figure it out.
 
We are having the exact same issue in Oregon with Regence, Cigna and Providence. We have also been told to appeal but haven't received any response back at this time. Please share any ideas/tips you may find. Thank you!
 
KatieV7 said:
Nothing yet. I finally have a provider rep looking into it for me though. She has been really helpful and seems to really want to get to the bottom of it. Its starting to sound like there must have been some sort of change to the rule as it is affecting so many different payers nation wide. I will definitely let you all know what I find out. I did try appealing some of them and they came back paid so that's a good sign. However, not ideal to have to appeal them all, all the time.
Click to expand...
Would you mind sharing what information you included in the appeal?
 
Honestly, nothing special. Just that it shouldn't apply to global because it's a supply, not a procedure. And that they have always paid it in the past. I didn't spend too much time on it just wanted to give it a try to see what would happen. I didn't even add any proof or attachments of any kind.
I am still waiting to hear back from the provider rep I'm working with, last I spoke to her she was hoping for a resolution this week. I'm slowly loosing hope on that though...
 
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