Author Topic: Occupational Therapy Extended Testing  (Read 123 times)

June Lawrenz

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Occupational Therapy Extended Testing
« on: November 11, 2021, 09:53:43 PM »
My OT provider is being denied for extending testing needed during an evaluation;
Line 1:  96112          Developmental Testing/Extended-1st hour
Line 2:  97165-59     Evaluation
The denial states "procedure code incidental to primary procedure".
We believed that CMS retracted their decision to no longer allow this pairing (January 1, 2020) and some carriers will reprocess and pay. But I have one carrier that refuses to allow it and states their system won't allow them to override it so I must appeal it.

What are we doing wrong?

Michele

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Re: Occupational Therapy Extended Testing
« Reply #1 on: November 13, 2021, 01:15:42 PM »
First, I am not a certified coder.  Just wanted to make that clear.

Are those the only two lines on the claim? 

If so, my first thought is wouldn't the 59 modifier go on the 96112 line?  I would put the evaluation on line 1 and have the testing on the 2nd line with the 59 modifier. 

Normally you would put a 25 modifier on an E&M if that was billed, but the 97165 doesn't fall under the E&M codes, so I would think the 59 should be on the 96112. 

But again, I'm not a certified coder so that may not be the issue.
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June Lawrenz

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Re: Occupational Therapy Extended Testing
« Reply #2 on: November 18, 2021, 08:56:48 PM »
Hi - Thanks for responding. I've had other carriers pay for these services coded in the exact same manner. I was even instructed by Molina that this was the correct order per CMS. The exact coding on the claims was;
Line 1:  96112          Developmental Testing/Extended-1st hour
Line 2:  97165-59     Evaluation
Line 3:  99072          PPE (which 75% of the time the carriers deny).
I am also not a coder, and I also believe that 97165 does not fall under E&M. The NCCI Edit list shows this to be accurate. My problem with this is that I can't find the NCCI edit list on the CMS site. I have a list from WebPT but am unsure if Regence will accept it or not.
We actually found another patient under the same exact plan; Regence Uniform Medical Plan - same exact Group # and all - and they paid this exact scenario. So I guess when we Appeal they will either pay this, or they'll take it back on the other patients claim.

Michele

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Re: Occupational Therapy Extended Testing
« Reply #3 on: November 19, 2021, 02:45:53 PM »
Hmmmmm.  So it sounds like it may just be an error on their part, but like you said you have to hope they don't decide the error was in paying, and they reprocess and take back the money on the other claim.  But from what I see it appears to be allowed separately.
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June Lawrenz

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Re: Occupational Therapy Extended Testing
« Reply #4 on: November 23, 2021, 09:47:42 PM »
Thank you.

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Re: Occupational Therapy Extended Testing
« Reply #4 on: November 23, 2021, 09:47:42 PM »