Author Topic: Billing Optumhealth for 98941 when Clinical Submission Form authorizes 98940  (Read 2194 times)

2012billingrep

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Has anyone had to deal with billing Chiropractic services through Optumhealth? You are required to submit a Clinical Submission Form for certain patients and then wait for authorized visits. In this case the patient was authorized 11 visits and the supported level of CMT is 98940. The patient returned a few days later with a new issue that required a new diagnosis to be added to the original complaint. This would now require a CMT of 98941. We are told we cannot amend the Clinical Submission Form and also told NOT to submit a new Clinical Submission Form and to treat the patient for both the original and current complaints under the initial authorized 11 visits. I called Optumhealth and they said not to include the new diagnoses in the claim. How then am I supposed to bill for 98941 when :
a. the Clinical Submission Form only authorizes 98940 so it would automatically reject my claim for 98941
b. Optumhealth tells you not to add any new diagnosis codes to the claim but to treat the patient for everything the patient is complaining of under the 98940.

Any advice??


Merry

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Not my specialty but I am sure someone will pop up and share.

DMK

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For us, Optum has only had to notified that the patient was being seen and for what.  They give is a date range for the patient's treatment.  I will bill with correct diagnosis and procedures (even in it's not the same as what was originally submitted, but it generally stays the same) for the authorized date range.  I have not had a problem to date. (but everything's been know to change!)

2012billingrep

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DMK, when you say you bill with the correct diagnosis and procedures that you add in diagnoses and procdures not on the original submission form?

shanbull

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Huh, this is weird. If you do try to bill for 98941 they will still only reimburse for 98940. Since the symptom was new, this technically counts as a new "incident" and would therefore warrant a new and updated treatment plan according to conventional wisdom. I would appeal what they told you, but Optum is one of the strictest private insurers about chiro policy, so expect the original decision to stand. Still, it's worth a try. Maybe they will at least increase the # of visits to allow the new problem to be addressed on its own.
« Last Edit: February 24, 2014, 09:32:52 AM by shanbull »

DMK

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DMK, when you say you bill with the correct diagnosis and procedures that you add in diagnoses and procdures not on the original submission form?

I bill CORRECT codes (diagnosis and CPT) for what was done.  However, the OPTUM authorization service I have to go through only gives me a date range for services.  I don't have to give them CPT codes, only diagnosis and patient's report of pain level.  I have not had a problem getting paid YET. 

I do understand your dilemma, because patient's can have an additional problem come up, or a new injury.  You should be able to update your treatment plan so that it's all correct.

2012billingrep

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Thanks for the responses. Am still stuck on the issue but hopefully will figure it out

shanbull

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Let us know how it goes! I am always curious to see the outcomes other people have with this stuff.