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Why are we getting denials

  1. Default Why are we getting denials
    Medical Coding Books
    Hi,
    Hopefully someone can help. I work in a pediatrician's office and we bill office visit and the urinalysis CPT code 81000 on the same visit. Apparently Healthchoice insurance denies the CPT code 81000 each time asking for the NPI# and the referring doctor name. I write it in on the corrected paper claim and we go in circles each time. Is there a modifier we need to use or is this just not a payable code?

  2. Default
    How are you doing the U/A? Microscopy? Automated? Both?

    Do you have a CLIA License? There could be a few issues at play here. Please add any specifics about what you're doing for the U/A and how you are billing.

    Thanks.

  3. Default
    To piggyback on emcee's post, the most likely (but certainly not definitive) reason is that you are not putting modifier QW on the CPT code (assuming your facility is CLIA-waived)

    By not putting the modifier on, the insco may be thinking that you are doing labs under some supervising physician and they are looking for a separate NPI from the doc ordering the tests at your facility

    Just a guess

  4. #4
    Default
    81000 should not require QW modifier.
    Kelly A Mcfadyen, CPC

  5. Exclamation 81000 is a high complexity code
    unless your doc has a CLIA as a high complexity lab you should be using the code 81002 82570 81003 all with modifier QW It is not worth billing a high complexity UA code unless you do hundreds of these a day as the equipment even in Canadian dollars for the BTNX setup would take years to pay for itself and the 81000 code does not pay that much more anyway. If you have a young sexually active female on potentially teratogenic meds you can also do 81025QW If audited your CLIA application needs to list these tests and the source of the sticks I like BTNX especially in Canadian dollars

  6. #6
    Default
    I'm pretty sure you should be billing 81002 for your UA. Check/verify the CPT description. Also 81002 does not need a QW modifier to be recognized as a waived test.

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