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co mgmt claim denials

  1. #1
    Default co mgmt claim denials
    Medical Coding Books
    I have started getting denials from Medicare and a United Healthcare Medicare replacement for co management of cataract surgeries. We bill with the -55 modifier and POS 11.

    The denial message is that "The Centers for Medicare and Medicaid Services has identified certain procedures that are rarely or never performed in a non-facility setting."

    Anyone else getting these? Anyone who understands billing knows that the post-op care is nearly always going to take place in the office.

  2. #2
    Smile
    Your codes have to match apples to apples with the surgeons codes. I require that my MD offices send a copy of the claim to my OD's before the OD's can submit the claim.

    Make sure your MD/Surgeon used the correct modifier on their claim to allow you to bill for the post operative period. Sounds like they may have left it off and now the payor is thinking your trying to bill a surgery with POS 11.
    [COLOR="Blue"]Kandy Morris CCS, CCS-P, CPC, CPB, CPC-I, CPMA, CEMC, CPOC
    AHIMA-approved ICD-10CM/PCS Trainer & Ambassador
    AAPC PMCC Approved Instructor
    Email: kandymorris3@yahoo.com

  3. #3
    Location
    Columbia, MO
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    Also be sure to use the V code for either post op aftercare or follow up as the dx code, do not code the cataract since it does not exist.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
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    Debra, are you sure about that? I was always told like Kandy said that our codes had to match theirs, so I've always billed it with whatever cataract diagnosis the surgeon gives me.

  5. #5
    Location
    Columbia, MO
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    12,912
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    Quote Originally Posted by stacisharp View Post
    Debra, are you sure about that? I was always told like Kandy said that our codes had to match theirs, so I've always billed it with whatever cataract diagnosis the surgeon gives me.
    I am 1000% sure. The procedure must match the surgeons, but the diagnosis is the patient's and must reflect the patient at the time of the visit. It is either aftercare or follow up , as there is no longer a cateract.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Thumbs up
    Debra is correct! You have to match the other providers codes, HOWEVER, the patient no longer has the cataract so the V43.1 is appropriate. I second Deb's 1000% assurance!
    Last edited by mzkandyd; 10-19-2014 at 11:37 PM. Reason: spelling
    [COLOR="Blue"]Kandy Morris CCS, CCS-P, CPC, CPB, CPC-I, CPMA, CEMC, CPOC
    AHIMA-approved ICD-10CM/PCS Trainer & Ambassador
    AAPC PMCC Approved Instructor
    Email: kandymorris3@yahoo.com

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