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Medicare denying 96367?!?!?!

  1. #1
    Default Medicare denying 96367?!?!?!
    Medical Coding Books
    We just received denials today on the new infusion codes. We billed 96367 as an add-on code along with 96365 (per 2009 CPT guidelines) but Medicare denied 96367 saying that they do not pay for add on codes unless they are billed with the primary code. When we called to explain that we did bill the appropriate primary code, we were told that their computer does not show that 96365 is the primary code for 96367, and that the only thing we can do is appeal. They of course would not tell us what the primary code is for 96367.

    Has anyone else gotten this denial? Should we just appeal, or should we call back and try to work up the tiers to get someone who can understand and help us?

  2. Default Need more Info
    Hi, what drugs are you billing? Are you using a 59 modifier on the second code?

  3. Default
    Based on what I could find, CPT 96367 IS an add-on code for 96365 IF the infusion is secondary or subsequent to the initial service and the service is different. Both services should be administered through the same IV line. Under this situation, I don't think a modifier is appropriate.

  4. #4
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    Quote Originally Posted by rizeninme View Post
    We just received denials today on the new infusion codes. We billed 96367 as an add-on code along with 96365 (per 2009 CPT guidelines) but Medicare denied 96367 saying that they do not pay for add on codes unless they are billed with the primary code. When we called to explain that we did bill the appropriate primary code, we were told that their computer does not show that 96365 is the primary code for 96367, and that the only thing we can do is appeal. They of course would not tell us what the primary code is for 96367.

    Has anyone else gotten this denial? Should we just appeal, or should we call back and try to work up the tiers to get someone who can understand and help us?
    Work up the tiers until you get someone who can help...or you can check your carrier website, they may have a provider outreach contact person. That is the ONLY way I have been able to resolve most erroneous issues with our carrier (TrailBlazer). Best of luck to you!!
    Lisa Bledsoe, CPC, CPMA

  5. #5
    Angry This is dead wrong!!!
    We just received a lot of denials today for 96367. Only our denials were saying 96367 and 96366 were content to 96413 (initial chemo infusion). Someone from our billing department will be discussing these with our medicare rep thursday of this week.

    As soon as I get a response on how to deal with these I will post the information here to share. I figure that this has got to be a system issue and the new codes weren't updated correctly.
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

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