Medical Billing Forum
Billing => Billing => : BREWERBILLING February 28, 2011, 01:21:30 PM
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We have been getting denials on breathing treatments and I have done everything I know to correct to get paid. We've used modifiers. Re-ordered the claim importance. Anytime we do a PFT and have injections we get denied for the breathing treatment. Can anyone offer any help? Thanks in advance!
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What are they denying for? Reason? Is it one carrier, or across the board?
Michele
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Denial code says C04 regarding the modifier. So when I bill with a modifier of 51 -- it still denies. I've tried the billing the first and then billing the 2nd 2 with 76 as well. None of the three ways has worked. It is with Medicare, Medicaid and BC.
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Have you tried calling and talking to a customer service rep? With BC you may be able to reach a provider rep. They are usually helpful. With Medicare I would ask them to point you to the LCD/NCD that covers this topic. I'm not familiar with the problem you are having, but that is what I would do.
Michele
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Let's say you have an office visit 99204, blood draw 36415, chest xray 71020, breathing tx 94640 and PFT 64060 for 786.2, 244.9, 780.79, 493.90 and 780.60 ---- what would your billing look like with modifiers etc and that might help me see where I'm messing up....
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Oh and I have contacted Medicare asking why the denial -- their standard response is "we can't tell you how to bill you have to figure it out". They won't even refer me to anyone that can answer the question.
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You should specifically ask them if they can point you to information on the LCD or NCD on breathing tx or 94640. You aren't asking them to teach you how to bill. Anyway, I found the following on the LCD's:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=14749&ContrTypeId=1&ver=17&ContrNum=00520&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA|CAL|NCD|MEDCAC|TA|MCD&ArticleType=Ed|Key|SAD|FAQ&PolicyType=Final&s=All&CntrctrType=1&KeyWord=94640&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAA&
It looks like the only dx you have that would be medically necessary for the treatment is the 786.2. I'm not sure how you have it coded, but I can't tell you how to code it either. (I'm not a certified coder and I don't have the notes/chart.) The provider should be sending it over to you coded, unless you are the coder. But if you look at the web page above it does indicate what dx's it is covered for and which ones it isn't.
Good luck!
Michele
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Oh and I have contacted Medicare asking why the denial -- their standard response is "we can't tell you how to bill you have to figure it out". They won't even refer me to anyone that can answer the question.
That's correct, insurance carriers are NOT allowed to tell you how to code or bill charges. They are not even supposed to tell you the amount needed to reach the deductible.
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Judging from the link you gave me -- I am billing correctly, insurance is just not paying when there are multiple services rendered that day. Thanks for the help, but it looks like this is a freebie for our patients.