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Denial-0ptometry

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Pay_My_Claims:
OK, need my Opthalmology & Optometry specialist on this one.  My provider is getting major denials from Medicare billing 92004 with dx 401.9 (hypertension unspecified).  It is denying for medical necessity. Since Medicare does not cover routine eye exams, I believe he needs another dx to justify the exam. EX, if they had blurred vision which was a result of the HTN  etc am I correct? Now I am not asking you to give me DX for him to use to get the claim paid, I know thats fraud. Medicare will flag it if he doesn't have documentation, just looking for some advice

Thanks

medauthor:
Pay,

Have you seen this site?  http://chppm-www.apgea.army.mil/doem/coding/PRIMER.ASPX

Pay_My_Claims:
Yes, been on that often, thanks though MedA

oneround:
Char, have you checked the LMRP for your state?  Some DX's when billed with 92004 require two or more CPT's and or DX's

Pay_My_Claims:
yes, the issue is there is no "chief complaint" the 401.9 is a DX, and for Medicare to pay for an eye exam it needs that. You can do a glaucoma screening or a diabetic exam, but to code with that, denies for medical neccesity.

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