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Recouped for "bundling" but only 1 code billed?

  1. #1
    Default Recouped for "bundling" but only 1 code billed?
    Medical Coding Books
    I'm hoping someone can help shed some light on this issue, i've tried researching a bit but just can't seem to find the info I need.

    We have received a request for refund from Tricare for an FCE (functional capacity exam) 97750, this is an exam usually performed by an OT testing fuctional levels to determine if the patient is fit for duty etc. We received auth for 24 units of 97750 and billed just 24 units of 97750 by itself. It was paid however the payment was automatically reduced to pay only 12 units based on "industry standards". I guess I get why they reduced payment although I don't agree and unfortunatley the person who use to handle our Tricare accounts never properly appealed so we were stuck with the reduced payment. Now I've received this recoup letter telling me due to codes not being payable in the combination billed they are recouping the full amount they paid on the claim which is $369, not a small chunk of change. Of course I immediatley appealed this because there was only 1 code ever billed on the claim and asked them to either withdraw the request or for them to provide addtional documentation to substatiate their request because it just didn't make sense. My appeal was denied stating " We are using industry standards. 97010 is a passive procedure and is bundled into the active physical codes on your claims. The recoupment stands"

    I guess I just do not understand how they can assume "bundling" on a code that 1) was never billed on the claim 2) not supported in our documentation of ever being performed. I totally understand that with PT billing 97010-hot/cold packs are automatically bundled into a regular therapy session but there is not a stitch of documentation that states we used them in this case and its something we always note even if we don't bill that particular carrier due to our contract requirements.

    I read somewhere that 97750 can't be billed by itself that it needs an eval code so I don't know if that may be part of the issue but at this point the claim is too old to try and ammend what we billed anyways. I've never come across this type of issue with any of our carriers and have never heard of this. Does this recoupment sound right? I was planning on appealing again stating there is nothing documenting we billed or even used the hot/cold packs-97010 and its being assumed it was done as part of the visit but it wasnt. Any help or thoughts are much appreciated

  2. #2
    Default
    Quote Originally Posted by honeybee View Post
    I'm hoping someone can help shed some light on this issue, i've tried researching a bit but just can't seem to find the info I need.

    We have received a request for refund from Tricare for an FCE (functional capacity exam) 97750, this is an exam usually performed by an OT testing fuctional levels to determine if the patient is fit for duty etc. We received auth for 24 units of 97750 and billed just 24 units of 97750 by itself. It was paid however the payment was automatically reduced to pay only 12 units based on "industry standards". I guess I get why they reduced payment although I don't agree and unfortunatley the person who use to handle our Tricare accounts never properly appealed so we were stuck with the reduced payment. Now I've received this recoup letter telling me due to codes not being payable in the combination billed they are recouping the full amount they paid on the claim which is $369, not a small chunk of change. Of course I immediatley appealed this because there was only 1 code ever billed on the claim and asked them to either withdraw the request or for them to provide addtional documentation to substatiate their request because it just didn't make sense. My appeal was denied stating " We are using industry standards. 97010 is a passive procedure and is bundled into the active physical codes on your claims. The recoupment stands"

    I guess I just do not understand how they can assume "bundling" on a code that 1) was never billed on the claim 2) not supported in our documentation of ever being performed. I totally understand that with PT billing 97010-hot/cold packs are automatically bundled into a regular therapy session but there is not a stitch of documentation that states we used them in this case and its something we always note even if we don't bill that particular carrier due to our contract requirements.

    I read somewhere that 97750 can't be billed by itself that it needs an eval code so I don't know if that may be part of the issue but at this point the claim is too old to try and ammend what we billed anyways. I've never come across this type of issue with any of our carriers and have never heard of this. Does this recoupment sound right? I was planning on appealing again stating there is nothing documenting we billed or even used the hot/cold packs-97010 and its being assumed it was done as part of the visit but it wasnt. Any help or thoughts are much appreciated
    It sounds like they're requesting a refund on 97010 - right? And you never billed that? That should be an easy fix, if so. Call them and inform them that they made a mistake, and that you never billed the code. If they try to argue with you, drill them for information:
    What date was the claim received?
    What were the total charges?
    Ask them to image it, if possible, and read off the NPI in box 33a, and verify the billing provider's name and address, and the rendering provider's name.
    Find out when it was paid - get the check # and total paid amount, including a breakdown of all charges paid on the claim with individual paid amounts. Find out when the check cleared.
    You can't refund something that you never billed, and were never paid for - period.

    97010 and 97750 are completely unrelated and shouldn't have anything to do with one another; as long as the documentation supports the number of units billed, and there is a written report, you should be able to report 97750 (with or without 97010). Double check to make absolutely sure that you didn't bill any other services on the same DOS, and if you did, verify that they really don't bundle together by checking them against NCCI edits - I'd probably do that, before calling, if I were you...
    (http://www.cms.gov/NationalCorrectCo...CCIEP/list.asp)

    If they keep insisting that they're correct, ask them what exactly they mean by "industry standards" - what industry? Whose standards? Where can you find more information on that? You're legally entitled to full written-disclosure of their payment policies; remind them of that.

    Don't let them screw you around, just because they're Tricare. They'll walk all over you if they get the opportunity. Unfortunately, you're probably going to encounter a customer service rep that is unhelpful, and inadequately trained to provide you with a logical explanation for the denial (if they can even answer the questions listed above) - be prepared to have to ask for a supervisor, if necessary.

    Tricare's provider services department has been a thorn in my side for a while, now - many of their reps don't know much (if anything) about healthcare (I had one that treated the word 'subcutaneous', like it was written in a foreign language) - and they don't end up doing much more than reading the EOB reason code out loud to you. I gave them a pretty harsh complaint about it, when appealing my own ridiculous denial issue a little while ago.

    It's a huge waste of time to have to spend an hour or so on the phone, trying to get an explanation, that someone doesn't have the expertise to provide and then to have to submit a written appeal, and try to see that get through the process successfully; it's especially annoying when you're in the right. Good luck!

  3. #3
    Wink
    Thank you so much for your advice, very much appreciated

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