Author Topic: 20552 & 64405  (Read 11284 times)

mbloom

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20552 & 64405
« on: June 24, 2013, 06:14:40 PM »
I am having the hardest time with billing these 2 codes together. Should they always be done on the same side, using LT or RT on both? what does it mean to be incidental of each other??? Soooo lost!!!

Billergirlnyc

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Re: 20552 & 64405
« Reply #1 on: June 24, 2013, 11:17:26 PM »
A good place to start with any code is ALWAYS your CPT book. Another good place is the Medicare LCD in your area for pain management? They have one. The next place is the carrier guidelines, because insurances like say Oxford follow Medicare's rule completely when it comes to billing either of the Trigger Point CPT codes (20552 (1 or 2 muscles) 20553 (3 or more muscles) and only allow ONE ICD-9 code that MUST be the primary DX or it won't be paid (remember you can only bill icd-9 codes documented on the superbill or in the patient's chart, but they only allow 1 DX code like Medicare does) Thankfully not all insurances follow this rule (thankfully).  Do you know that the medication is already built into the Trigger Point codes? Meaning you don't bill the medicine separately? Do you know the the 20552/20553 TP codes can't be billed w/a 50 mod (bilateral) thus can't be billed w/LT/RT? All of this is in your CPT book. Nothing is hidden or even hard to decipher. I don't say this to be mean but I say it because SO many people forget that they're CPT book holds the key to all the answers they need regarding the codes themselves. I'd rather show you HOW to find the answer, than just throw the "right" answers at you. Some carriers only allow a range of DX codes for both codes. You should be checking the website of each one that's denying you to get their guidelines. The Medicare LCD for pain management in your area is a good start, but some carriers REALLY hammered pain management and are far more extreme than Medicare on these codes, thus why I say check with each carrier's guidelines. Usually when you verify the benefits for both both CPT codes it's a great idea to ask them if they allow BOTH on the same day or if there are any restrictions. Most carriers have none but some do.

Now with all that said the 64405 (occipital nerve block) CAN be billed w/50 mod or LT/RT and it's a primary code the TP/20552 is a secondary code and SHOULD have a modifer LIKE say 59 to separate it from the nerve block BUT understand WHAT 59 mod truly means, you'll also need to examine the DX codes for both codes to again ensure they're allowed. If you're doing a TPI and a Nerve block on the same part of the body for the same pain/DX code you'll be hard pressed to find any carrier who wouldn't rush to bundle/and or deny and they'll usually do it to the primary code and pay you on the secondary code. Also again and as a REMINDER you can't bill 20552/20553 w/50 mod or LT/RT mods because bilateral surgery isn't allowed . You also can't bill more than 1 unit no matter how many muscles are injected for the TP codes. The CCI on the TP is the conflict and it can ONLY be overridden by use of a modifier.  I bill for pain management and bill these codes ALL the time (mostly 20553) with nerve blocks occipital (64405) and (64400) trigeminal and usually get paid w/o issue. Every blue moon even w/all the modifiers some carrier will deny as incidental, but I usually get paid on appeals. One because I know the guidelines of each carrier we bill to and I know how to separate the 2 codes. BCBS likes to bundle or deny as incidental w/these 2 codes too. Again fact is you can override the CCI conflict w/a modifer to both codes. Oh and please note when you do get paid for both these codes after learning how to bill them correctly they're both subject to the multiple procedure reduction rule and some carriers will do this, which is why it's important that you code them properly on the claim form so the primary code isn't the one reduced (usually higher charge) but the secondary one is. Just a little suggestion. 

« Last Edit: June 24, 2013, 11:36:08 PM by Billergirlnyc »
Don't worry. Be happy.
~Dalia, CPC, CPC-H, RHIT.

mbloom

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Re: 20552 & 64405
« Reply #2 on: June 27, 2013, 06:44:02 PM »
Thank you! That was so informative.. This si my first time billing for client that does injections and I couldnt follow the superbill. Then when I asked why they were putting 2 unites next to 64405, they said that it was for 1 on each side. Then, they had 20552 with 6 units and I knew that I could use a modifier to distinguish between the procedures, but I could not tell if the proper criteria was there. They said it was 2 different procedures, do I just take their word for it?

Billergirlnyc

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Re: 20552 & 64405
« Reply #3 on: June 27, 2013, 10:07:09 PM »
No do not take their word for it. It's your job to know how to bill the things your client does, so your knowledge should trump theirs especially if you back it up with proof, which is in your CPT book. Do not bill the TP codes 20553/20552 with more than 1 unit. I had a client who had a biller who was billing this w/4 units and UHC would pay and then a year or so later UHC requested over $17K in refunds. They sought my services after the fact. I had to tell them the hard truth that UHC was correct that they overpaid them because the TP only allows 1 unit not 4. The kicker was that UHC wanted ALL their money back and wanted a corrected claim submitted before they'd pay again. It was a headache for everyone. Most carriers systems will catch the wrong units and change it or deny out right, but you can avoid that by billing a correctly the first time, because if they pay and you billed incorrectly they will come for their money upon an internal audit. Let me state this again, the TP codes only allow 1 unit no matter how many muscle sites are injected. The Medicare LCD for pain management also states this explicitly so be sure to download the one from your Mac provider. It's important you explain this to your client say to them that it's only 1 unit no matter how many muscles are injected. Counting the muscles injected then putting it where units go is bad billing and incorrect where the TP codes are concerned.

You also don't put more than 1 unit on the nerve block codes 64405 and or 64400 - you can either bill it with the 50 modifier to show both sides were injected (bilateral) or LT/RT if it's a single-sided injection. You don't put 2 units to indicate that both sides were injected, you use the aforementioned modifiers for these cpt codes. Also don't try to bill it like this: 64405-LT on one line then the next line, 64405-RT, doesn't work like that. You bill it 64405-50 if both sides were injected and keep the units at 1. The units remain 1 despite the scenario.

And you're client is right, both the nerve block and the trigger point injections are different but teach them how it's allowed to be billed, not what they think should be billed.
« Last Edit: June 27, 2013, 10:19:16 PM by Billergirlnyc »
Don't worry. Be happy.
~Dalia, CPC, CPC-H, RHIT.

mbloom

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Re: 20552 & 64405
« Reply #4 on: June 27, 2013, 10:46:50 PM »
I see....so that means that 64405 and 20552 will pay incidental. Or do I use a 59 on 20552 to indicate two separate procedures and should I be reading provider notes to make sure it should be billed as 2 separate procedures....


 :o

Billergirlnyc

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Re: 20552 & 64405
« Reply #5 on: June 28, 2013, 11:26:44 AM »
I see....so that means that 64405 and 20552 will pay incidental. Or do I use a 59 on 20552 to indicate two separate procedures and should I be reading provider notes to make sure it should be billed as 2 separate procedures....


 :o

They're NOT inherently incidental. SOME carriers don't pay for them on the same day per their policy or the patient's but this doesn't make them incidental across the board. If modifier 59 is appropriate in your situation then you can append it to the 20552 because the code allows it. But you still need to confirm with the carrier on their rules for doing both injections on the same day.

Now, when I say that 59 modifier can be appended it means it must follow the coding rules, which you can research to confirm and of course back-up with documentation (patient notes). You should always confirm with your client/the doctor that both procedures are properly documented so you know how to bill for it, so yes look at the notes (if you're a coder), if not then just ensure you client confirms the CPT codes to be billed via an encounter form/superbill. But you need to educate your client on how these codes CAN be billed regardless of what they circle or write on the superbill. I've never seen a doctor do a greater occipital nerve block in any other place than the facial/head area -- see this link ---> http://www.preferredpaincenter.com/occipital-nerve-block.html so you can better understand the type of injection a nerve block is, especially the greater occipital one. The TP codes 20553/20552 are injections in the MUSCLES NOT NERVES -- see this link to see what they are---> http://www.preferredpaincenter.com/trigger-point-injections.html# and I often seem them injected in the back area or neck area, but I've also seen it done in other areas too, but never in the head or facial area. So there SHOULD be 2 different reasons for doing both injections but perhaps in your case it's not. Check the documentation and with your client.

See my original response which covers some of this.
« Last Edit: June 28, 2013, 12:24:56 PM by Billergirlnyc »
Don't worry. Be happy.
~Dalia, CPC, CPC-H, RHIT.

mbloom

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Re: 20552 & 64405
« Reply #6 on: July 02, 2013, 02:30:03 PM »
Thanks again! Very, very helpful!