I'm hoping someone can help shed some light on this issue, i've tried researching a bit but just can't seem to find the info I need.
We have received a request for refund from Tricare for an FCE (functional capacity exam) 97750, this is an exam usually performed by an OT testing fuctional levels to determine if the patient is fit for duty etc. We received auth for 24 units of 97750 and billed just 24 units of 97750 by itself. It was paid however the payment was automatically reduced to pay only 12 units based on "industry standards". I guess I get why they reduced payment although I don't agree and unfortunatley the person who use to handle our Tricare accounts never properly appealed so we were stuck with the reduced payment. Now I've received this recoup letter telling me due to codes not being payable in the combination billed they are recouping the full amount they paid on the claim which is $369, not a small chunk of change. Of course I immediatley appealed this because there was only 1 code ever billed on the claim and asked them to either withdraw the request or for them to provide addtional documentation to substatiate their request because it just didn't make sense. My appeal was denied stating " We are using industry standards. 97010 is a passive procedure and is bundled into the active physical codes on your claims. The recoupment stands"
I guess I just do not understand how they can assume "bundling" on a code that 1) was never billed on the claim 2) not supported in our documentation of ever being performed. I totally understand that with PT billing 97010-hot/cold packs are automatically bundled into a regular therapy session but there is not a stitch of documentation that states we used them in this case and its something we always note even if we don't bill that particular carrier due to our contract requirements.
I read somewhere that 97750 can't be billed by itself that it needs an eval code so I don't know if that may be part of the issue but at this point the claim is too old to try and ammend what we billed anyways. I've never come across this type of issue with any of our carriers and have never heard of this. Does this recoupment sound right? I was planning on appealing again stating there is nothing documenting we billed or even used the hot/cold packs-97010 and its being assumed it was done as part of the visit but it wasnt. Any help or thoughts are much appreciated
We have received a request for refund from Tricare for an FCE (functional capacity exam) 97750, this is an exam usually performed by an OT testing fuctional levels to determine if the patient is fit for duty etc. We received auth for 24 units of 97750 and billed just 24 units of 97750 by itself. It was paid however the payment was automatically reduced to pay only 12 units based on "industry standards". I guess I get why they reduced payment although I don't agree and unfortunatley the person who use to handle our Tricare accounts never properly appealed so we were stuck with the reduced payment. Now I've received this recoup letter telling me due to codes not being payable in the combination billed they are recouping the full amount they paid on the claim which is $369, not a small chunk of change. Of course I immediatley appealed this because there was only 1 code ever billed on the claim and asked them to either withdraw the request or for them to provide addtional documentation to substatiate their request because it just didn't make sense. My appeal was denied stating " We are using industry standards. 97010 is a passive procedure and is bundled into the active physical codes on your claims. The recoupment stands"
I guess I just do not understand how they can assume "bundling" on a code that 1) was never billed on the claim 2) not supported in our documentation of ever being performed. I totally understand that with PT billing 97010-hot/cold packs are automatically bundled into a regular therapy session but there is not a stitch of documentation that states we used them in this case and its something we always note even if we don't bill that particular carrier due to our contract requirements.
I read somewhere that 97750 can't be billed by itself that it needs an eval code so I don't know if that may be part of the issue but at this point the claim is too old to try and ammend what we billed anyways. I've never come across this type of issue with any of our carriers and have never heard of this. Does this recoupment sound right? I was planning on appealing again stating there is nothing documenting we billed or even used the hot/cold packs-97010 and its being assumed it was done as part of the visit but it wasnt. Any help or thoughts are much appreciated
