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Thread: 96372 with depo shot medicaid denial

  1. #1
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    Default 96372 with depo shot medicaid denial

    AAPC: CPC Promo
    Does anyone know what Medicaid's rationale is for making injection code 96372 for a depo provera shot a non allowable charge? They won't pay enough for the reimbursement for the depo and they say that 96372 is non allowable (so we can't charge our patients for the injection either). Our doc was already having them bring their own depo provera, but now Medicaid won't pay for the injection fee. Now, our doc is wanting to send them to the free health clinic because they don't want to give free birth control shots. In the past, the nurses were billing the nurse visit code with the injections, but I advised them that it was inappropriate and the injection code should be used. It is causing a great deal of stress and I just want to make sure I am advising them correctly. They are sending patients to the health clinic and the health clinic is sending them back saying they have to have pap smear records or have the clinic do their pap smear before they will give the shot. Also patients are getting upset in the office. In addition, now we were told that Health Clinics may not serve patients with Medicaid since they have "insurance." I have told my doc that the only way I see is for him to see each patient prior to the injection and do counseling and document and then I can bill on time or if medical necessity warrants an exam. Doc says he just doesn't have time. He is the only doc in the office. Sure would appreciate a response from someone who has this solved!
    Last edited by OBcoder1984; 01-11-2013 at 11:55 AM.
    ObCoder MA,BS,CPC

  2. #2
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    I have not had this issue with Medicaid. Did this just start this year or has this been an on going issue for you?
    Herbie W Lorona Jr., CPC, CPC-H
    hlorona@up2parmedicalclinic.com

  3. #3
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    you are correct in that you cannot charge a 99211 for the injection, but you also cannot charge an office encounter for the physician to see the patient prior to a scheduled injection. If Medicaid has stated the injection admin in non payable with the depo J code then that is going to be the way it is, but first you need to verify that this is the problem. I have also had no issues with billing any covered drug with an administration code. Is it possible there are different issues? such as dx? Have you verified that Medicaid policy indeed states the drug is covered but the admin is not?

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
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    Medicaid has been denying since we changed from using the 99211 to the 96372 injection code. Our Medicaid biller said she was told it is a non-allowable charge. They deny it. We bill it with J1055 (now J1050) and V25.49. Any ideas?
    ObCoder MA,BS,CPC

  5. #5
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    We changed from the 99211 nurse code to the 96372 injection code about 3 months ago. My commercial payors are paying well. We bill 96372 and J1055 (now J1050) with V25.49. Any ideas?
    Last edited by OBcoder1984; 01-12-2013 at 03:58 PM.
    ObCoder MA,BS,CPC

  6. #6
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    Debra, I was hoping to hear from you. I really respect your advise on our posts. We bill 96372 with J1055 (now J1050) with V25.49. My Medicaid biller is the one that states that she was advised this is a non allowable code. I instructed the office in the change to the injection code and the Medicaid biller is the one that said her conference with Medicaid several months ago advised it was not allowable. I was using the Vcode that was being used along with the nurse code when I came here which was V25.49. Medicaid was paying on that with the 99211, but when I advised them we needed to change to the 96372 injection is when Medicaid began denying. I saw in another post that other billers were using V25.02 for the depo shots each visit, but that code states it is for the "initiation" of other contraceptive measures which led me to believe this would only be appropriate for the initial visit. What do you think?
    ObCoder MA,BS,CPC

  7. #7
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    Yes I would definetly get in contact with them and get more info as to why exactly they are not covering that code. I haven't ran into any type of issue with the Depo shot like that.
    Herbie W Lorona Jr., CPC, CPC-H
    hlorona@up2parmedicalclinic.com

  8. #8
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    Herbie, Thanks. What dx code do you use for the Injection of the Depo shot?
    ObCoder MA,BS,CPC

  9. #9
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    V25.40
    Herbie W Lorona Jr., CPC, CPC-H
    hlorona@up2parmedicalclinic.com

  10. #10
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    Herbie,
    Thank you. I will see if this is a dx code issue. I will give the V25.40 to our Medicaid biller. My experience is that calling Medicaid is like nailing jello to a tree, but I will indeed call. I will change my focus from the Procedure code for the injection to seeing if the dx is the problem as you and Debra advise. I would have thought the V25.40 "Contraceptive surveillance, unspecified" wouldn't best describe the visit since we know that the contraception being used is specified....depo. This has created such a disturbance in my office that I would appreciate staying connected to AAPC codng support world until this is resolved. I want to get this right. Thank you for the lifeline.
    Last edited by OBcoder1984; 01-13-2013 at 12:35 PM.
    ObCoder MA,BS,CPC

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