Author Topic: Billing L5000 to Tufts Health Plan  (Read 918 times)

footthebill

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Billing L5000 to Tufts Health Plan
« on: February 11, 2016, 12:17:20 PM »
I am having a hell of a time getting a claim processed for a patient with Type I diabetes w/ neuropathy and 4 toes amputated. Our podiatrist made her a shoe filler (L5000) and we've been trying to get her Tufts insurance to cover the service.
 I've tried swapping the dx codes so the amputation was the primary code and also w/ the diabetes as the primary code, but each time they deny it saying that a podiatrist is not eligible to provide this service/item.
 I'm trying to research podatry covered services w/ CMS and found plenty of info that states L5000 can be billed, but not necessarily WHO can bill for it. I fear the only way I can get Tufts to see the light is if I prove to them that CMS will pay for a podiatrist to provide the service/item.

 This is a claim from August 2015, so it's ICD-9 and 2015 fee schedule.

 Are there any pros in this area that can provide me any info regarding this...maybe a link that clearly states a podiatrist is eligible to bill for this?  I found plenty of "opinions", but nothing concrete.

 Thank you!!!!

kristin

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Re: Billing L5000 to Tufts Health Plan
« Reply #1 on: February 11, 2016, 02:03:46 PM »
Tufts...ick. I have only dealt with them once, but they were a nightmare. I finally had to get the patient involved in a three way call to them, and only then did they pay the claim. Was a pre-cert call done first to verify that the L5000 was a covered code under the patient's benefits, etc? In my case I was dealing with L3000, and I had done the verification call first, and could use that as evidence of why the claim should be paid.

All I can tell you is that I have billed L5000 for a podiatrist to CGS DMERC a few times, and it always paid, no problems.

footthebill

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Re: Billing L5000 to Tufts Health Plan
« Reply #2 on: February 11, 2016, 03:04:26 PM »
L3000 is it's own special pain in the butt.

Do you recall which diagnosis codes you used and in what order for L5000 when you billed it to CGS DMERC?

Thanks for the info!

kristin

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Re: Billing L5000 to Tufts Health Plan
« Reply #3 on: February 11, 2016, 03:42:03 PM »
In both cases, the claims were billed as:

L5000-KX modifier, with a dx of 250.60

footthebill

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Re: Billing L5000 to Tufts Health Plan
« Reply #4 on: February 11, 2016, 03:43:08 PM »
hm, interesting. So you didn't need the dx for the amputation?

kristin

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Re: Billing L5000 to Tufts Health Plan
« Reply #5 on: February 11, 2016, 05:36:59 PM »
No, not for CGS, just DM dx. Tufts could be different, not sure.