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Denials:experimental Or Investigative

  1. #1
    Default Denials:experimental Or Investigative
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    Hi All,

    I wanted to know if anyone can help me with a query regarding PAIN MANAGEMENT coding denials.

    I am a working for a pain management doctor and we are getting denials for the CPT CODE:64613 and few other CPT codes in the 64XXX series from Insurance carriers when billed with ICD: 728.85 and other 72X.XX series codes as Experimental or investigational even when submitted with operative notes/medical records.

    Kindly guide me how to take care/avoid these denials in the near future. A link for any LOCAL MEDICAL REVIEW POLICY OR LCD for checking the pain management code would be quite helpful.

    Regards..

  2. #2
    Location
    Charleston, South Carolina
    Posts
    641
    Default
    If these are truly investigation and part of an approved clinical trial, you may need clinical trial modifiers. If you would like some help with this, feel free to email me privately.
    Machelle Morningstar, CPC, COC, CEMC, COSC
    AHIMA Approved ICD-10-CM/PCS Trainer

  3. #3
    Location
    Madison Area Chapter in Madison WI
    Posts
    113
    Default
    Quote Originally Posted by talukdar.c View Post
    Hi All,

    I wanted to know if anyone can help me with a query regarding PAIN MANAGEMENT coding denials.

    I am a working for a pain management doctor and we are getting denials for the CPT CODE:64613 and few other CPT codes in the 64XXX series from Insurance carriers when billed with ICD: 728.85 and other 72X.XX series codes as Experimental or investigational even when submitted with operative notes/medical records.

    Kindly guide me how to take care/avoid these denials in the near future. A link for any LOCAL MEDICAL REVIEW POLICY OR LCD for checking the pain management code would be quite helpful.

    Regards..
    The phrase "experimental or investigational" usually means that the procedure has not been proven to be safe and/or effective. This happens quite a bit with new procedures or new ways of performing the procedure. If you have information that supports that the procedure HAS been proved safe and effective, share that info with the payer. It may make a difference.
    Happy Coding, Claudia


    Claudia Yoakum-Watson, CPC
    Coding, Compliance, & Reimbursement Solutions
    [email]ccrsconsulting@tds.net
    ccrsconsulting.com - website

  4. #4
    Default
    Start with your govenmental and PPO payers, search their websites or call your provider rep to determine if they have coverage policies OR a list of what they term "experimental"/unproven procedures. Many larger carriers (i.e. BCBS and UHC) have this information easily accessible on the their web sites by CPT code and/or keywords. UHC in particular has coverage policies much like Medicare that, if covered, are only so it performed for specific (proven) diagnosis as reported in their particular policy.

    Julie, CPC

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