SIJ Injection in ASC setting

lcole7465

Guru
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Toledo, Ohio
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HI, I just started receiving denials from UHC for my pain management provider performing CPT 27096 in an ASC setting. Stating they only cover this in an office setting. Encoder has that this as a Nonsurgical procedure not Medicare allowable in an ASC. I know for most insurances when this procedure is performed in the ASC, HCPCS code G0260 is billed for the facility and 27096 is billed for the provider.

Has anyone else had denials for this reason.

Thank you
 

Henson65

Networker
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Did the provider use CT/fluoroscopy guidance for the procedure, and is it straight UHC or is it possibly a Medicare replacement plan? We do these all the time and don't run into any issues getting them paid......for Medicare/Medicare Like plans we utilize the G0260 always and 27096 for all commercial carriers as long as guidance is documented. If no guidance you would utilize 20552. I am surprised they are denying this code and saying they will only cover in an office setting since guidance is a necessary part of the procedure and most providers will not have access to CT or fluoroscopy in an office setting.
 

lcole7465

Guru
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Toledo, Ohio
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Yes he does use CT/Fluoro and it a UHC Medicare HMO Dual product. The ASC billed G0260 and I'm waiting to see if this gets paid.
 

Henson65

Networker
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40
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Since it is a Medicare replacement plan, G0260 should be billed in place of the 27096 for the facility as well as the provider.
 
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