CO-45 denial - getting paid nothing

[BWB]

Hello Everyone,

I am very new to medical billing in a small GA podiatry office and need your help. I am getting CO 45 denial codes that I am not getting paid anything for.  There are no other denial codes of explanation and the whole claim is effectively denied. My first thought is that maybe the office visit code is too high for the diagnosis, but I just don't know.

Please help

[asilva03]

Usually this is not a denial, but that you have billed over the Medicare allowed amount. Is there anything in the other fields like the deductible, etc?

[PMRNC]

I am very new to medical billing in a small GA podiatry office and need your help. I am getting CO 45 denial codes that I am not getting paid anything for.  There are no other denial codes of explanation and the whole claim is effectively denied. My first thought is that maybe the office visit code is too high for the diagnosis, but I just don't know.

You mention you are very new, you might want to get some further education in regards to Medicare particullarly. C045 is not a denial code, it's an adjustment code (contractual adj)  As asilva03 mentioned, if you have zero payments you need to look for deductible and maybe other codes indicated on the bottom of the Medicare EOMB
 

[BWB]

I am very new to medical billing in a small GA podiatry office and need your help. I am getting CO 45 denial codes that I am not getting paid anything for.  There are no other denial codes of explanation and the whole claim is effectively denied. My first thought is that maybe the office visit code is too high for the diagnosis, but I just don't know.

You mention you are very new, you might want to get some further education in regards to Medicare particullarly. C045 is not a denial code, it's an adjustment code (contractual adj)  As asilva03 mentioned, if you have zero payments you need to look for deductible and maybe other codes indicated on the bottom of the Medicare EOMB

There are no other codes and its not the deductible.  The co-45 adjustment just wipes out the bill.

[RichardP]

Take a look at this link:

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

On the right side of the page, note the heading: Claim Adjustment Group Codes .  Listed under this heading (after some narrative) are five codes - the first of which is "CO" = Contractual Obligation.  Then look at the list of numbers on the left side of the page and find "45" - Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use only with Group Codes PR or CO depending upon liability) .  Note that this "45" entry was last modified on 7-01-13.

Note also that insurance carriers do not cover every charge the doctor submits, including Medicare.

Put that all together, we see you are being told that this is a contractual obligation - where the charge exceeds ... contracted/legislated fee arrangement.

The Contractual issues that come to my mind would be these:

1.  Provider is not a contracted participating provider.  This is not likely the issue, because the EOB should still show payment, but paid to the patient.

2.  Carrier does not cover the charge submitted.  In this case, nothing would be paid to either the provider or the patient, and the EOB would look as you have described it.

What procedure and diagnosis codes did you submit?

[BWB]

It was 99213 and 64640.  And it was BC/BS. 

[Merry]

http://downloads.cms.gov/medicare-coverage-database/lcd_attachments/30153_18/L30153_MS007_CBG_010112.pdf

I just found this link..Was the injection for tarsal tunnel or Morton's neuroma. They are addressed here.

On the other hand, wouldn't you use -25 modifier

Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.

[RichardP]

See this take on 64640 from Blue Cross/Blue Shield of Florida:

http://blueline.staywellsolutionsonline.com/Past/Winter2010/22,Wi10BC2

And this question and answer, from here:

http://www.podiatrym.com/search3.cfm?id=6422

Q:  A patient was seen in our office for pain 3rd interspace right foot. An ultrasound confirmed the presence of a neuroma. In the office, the patient was given sclerosing nerve injections (CPT 64640) to the interspace at intervals of every 10 days for a series of 6 injections.

The insurance company denied the claims stating "surgery performed in the office" is not a covered benefit. I have appealed to the insurance company stating this is an injection that was given in the office, and not an open, cutting procedure. Any suggestions would be helpful.


A:  Codingline Response: On the issue of the payer denying your office "procedure", CPT is divided into sections: E/M, Surgery, Pathology and Laboratory, Medicine, etc.  The injection you are referring to "resides" under "Surgery" (along with cutting toenails and applying a cast). So, if this patient's insurance plan benefit structure language excludes ALL in-office surgery [coding] from reimbursement, then the insurance company's denial of your claim is correct, and you may only be left with charging the patient.

[PMRNC]

Sure hope we are looking at the chart documentation first.

[RichardP]

This comment could be viewed as nit-picking.  I view it as "clarification". 

Looking at the chart documentation should tell the doctor or coder whether they are sending the proper coding to the Insurance Carrier.  But looking at the chart documentation won't tell them anything about why the Carrier is paying nothing on the code.  The Insurance Carrier is in no position to claim/prove that the chart documentation does not support the code - as this situation is not an audit.  So looking at the chart cannot help the doctor or coder understand why the carrier is paying nothing.

However, if BC/BS is claiming that this code falls under the "Surgery" category, and if this patient does not have coverage for surgery ...

I don't think anybody here is trying to solve her problem for her.  Rather, we are providing some information through which she can learn some possible reasons why BC/BS might be paying nothing on this particular code - beyond what you have alread said.  She did say she was new to this.

[Merry]

 <<Codingline Response: On the issue of the payer denying your office "procedure", CPT is divided into sections: E/M, Surgery, Pathology and Laboratory, Medicine, etc.  The injection you are referring to "resides" under "Surgery" (along with cutting toenails and applying a cast). So, if this patient's insurance plan benefit structure language excludes ALL in-office surgery [coding] from reimbursement, then the insurance company's denial of your claim is correct, and you may only be left with charging the patient.>>

So correct..surgery is considered in CPT language from codes that are 10000 to 69999. Even though it was an injection, surgery does not always constitute an open incision or what people not in this industry would consider surgery. You must follow the CPT guidelines.
Since so much podiatric surgery is performed in office, it would be prudent for someone to check the insurance coverage before the procedure is performed.

[PMRNC]

Does this maybe help?

CPT Code Clarification for Treatment of Interdigital Neuroma

The American Medical Association (AMA) included two additional codes (64632 and 64455) for treating interdigital neuromas (e.g. Morton’s Neuroma) in the CPT® 2009 Standard Edition (CPT/Current Procedural Terminology) codebook.

Code 64632 (destruction by neurolytic agent; plantar common digital nerve) should be used when a qualified provider injects a neurolytic agent into an interdigital neuroma.

Code 64455 (injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) should be used when an injection of an anesthetic agent and/or steroid is used to treat an interdigital neuroma.

Physicians should no longer use CPT code 64640 (destruction by neurolytic agent; other peripheral nerve or branch) to describe the treatment of interdigital neuroma, as the CPT codes distinctly clarify which nerve is being treated.

Note: CPT codes 64632 and 64455 are limited to once per foot, per visit, regardless of the number of injections used.



http://blueline.staywellsolutionsonline.com/Past/Winter2010/22,Wi10BC2

[RichardP]

Linda - that wording is at the first link in my [second] post above.  Maybe you were just making it more visible?