No PMT for 92012 why?

[javed0076]

We are billing 92012 with physical examination (99381-85) CHDP claim, but we are not getting paid for 92012.  Can any one let me know why this is happening??

Ins - Alameda Mcal, CA

[Michele]

Usually a 92012 is billed by an optometrist or an ophthomalogist and usually neither of those bill 99381-85.  I've never seen any provider who billed for an eye exam along with a physical.  That is probably why the eye exam is being denied.  What are the credentials of the provider?

[javed0076]

Provider's specialty is Pediatrics.

We are billing CHDP Physical Ex. (99381-85 with mod 25) claims including with Snellen or Equivalent (92012), Audiometric (92552/51) and Hemoglobin or Hematocrit (85018 QW).

All were getting paid, excluding 92012.

Please let me know is there any extra modifier needed or any other reason for denials?

[Michele]

I actually asked what the credentials were as opposed to the specialty because many insurance carriers only allow the 92012 (or other eye exam codes) when billed by an OD, or MD with ophthomological training.  I don't believe most carriers will reimburse the 92012 when billed by a pediatrician.  I also don't believe there is a modifier that would change that.

[PMRNC]

What was the explanation on the EOB?

I do pediatrics and we've never broken out the eye exam as it's considered a part of the physical so long as it's documented. I would imagine it's not a covered expense broken out by the doctor and instead is bundled.  I'm not exactly sure on that but again, we've never billed separately for it UNLESS there was a suspected problem and then it was billed but also a referral to Optometrist or Ophthalmologist was given. Off the top of my head I can't say I remember one to look up but have you asked the carrier?