Medical Billing Forum
Medical Billing Forum - Get all of your billing & coding questions answered here!
Welcome,
Guest
. Please
login
or
register
.
Did you miss your
activation email
?
1 Hour
1 Day
1 Week
1 Month
Forever
Login with username, password and session length
News:
How to Complete CMS 1500 Forms
- Quickly & Easily Learn How To Fill Out CMS 1500 Forms Step by Step ...With No More Guess Work![/size]
Home
Help
Search
Login
Register
Medical Billing Forum
»
Coding
»
Coding
(Moderators:
Alice Scott
,
Michele
) »
Denial-0ptometry
« previous
next »
Print
Pages: [
1
]
Author
Topic: Denial-0ptometry (Read 9576 times)
Pay_My_Claims
Guest
Denial-0ptometry
«
on:
August 31, 2010, 04:37:50 PM »
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
Logged
medauthor
Full Member
Posts: 129
Re: Denial-0ptometry
«
Reply #1 on:
August 31, 2010, 04:47:01 PM »
Pay,
Have you seen this site?
http://chppm-www.apgea.army.mil/doem/coding/PRIMER.ASPX
Logged
Michelle Rimmer, CHI, CPMB
President-Professional Medical Billers Association
Owner-ABA Therapy Billing Services
Author, 'Medical Billing 101' and 'Coding Basics: Understanding Medical Collections
Pay_My_Claims
Guest
Re: Denial-0ptometry
«
Reply #2 on:
August 31, 2010, 04:53:18 PM »
Yes, been on that often, thanks though MedA
Logged
oneround
Full Member
Posts: 226
Re: Denial-0ptometry
«
Reply #3 on:
August 31, 2010, 05:22:34 PM »
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
Logged
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare
Pay_My_Claims
Guest
Re: Denial-0ptometry
«
Reply #4 on:
August 31, 2010, 05:38:26 PM »
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.
Logged
Medical Billing Forum
Re: Denial-0ptometry
«
Reply #4 on:
August 31, 2010, 05:38:26 PM »
Michele
Administrator
Hero Member
Posts: 5927
Re: Denial-0ptometry
«
Reply #5 on:
August 31, 2010, 10:00:40 PM »
It may just be that the doc doesn't realize he should be coding the complaint along with the reason. Like you said, pt states "I have blurred vision and high blood pressure" both should be on the claim. The doc may think "well the blurred vision is due to the high blood pressure" and just put the high blood pressure. Maybe education is the answer.
Logged
Sign Up for our FREE
Medical Billing Newsletter
Get a 10% discount on
Medical Billing Products
by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com
Pay_My_Claims
Guest
Re: Denial-0ptometry
«
Reply #6 on:
September 01, 2010, 10:24:54 AM »
Thanks Michelle, yes I notified him, and his partner and sent him the Medicare guidelines on it. HTN is factor in vision issues, but it is not a dx that I am currently aware of that Medicare allows as a reason for an eye exam. The only 2 that I know is for glaucoma, and diabetes.
thanks for everyones input
Logged
Michele
Administrator
Hero Member
Posts: 5927
Re: Denial-0ptometry
«
Reply #7 on:
September 01, 2010, 01:01:31 PM »
They allow for alot more than that, diabetic retinopathy, dry eye, visual floaters, way too many to name. We've been billing for OD's to Medicare for 15+ years.
Logged
Sign Up for our FREE
Medical Billing Newsletter
Get a 10% discount on
Medical Billing Products
by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com
Tilbrook
Newbie
Posts: 7
Re: Denial-0ptometry
«
Reply #8 on:
September 01, 2010, 01:27:30 PM »
I second Michele -- Medicare will pay for many more diagnoses than diabetes or glaucoma. Our ophthalmologists bill Medicare for the majority of their patients. You are correct that a medical diagnosis is needed, as Medicare will not pay for a routine eye exam. Most insurance companies won't in fact.
Logged
Pay_My_Claims
Guest
Re: Denial-0ptometry
«
Reply #9 on:
September 01, 2010, 02:25:12 PM »
@ Tilbrook Yes, and i wasn't saying they were the ONLY dx they cover for, but the guidelines that are automatically covered are for the diabetic yearly exam, and for history of glaucoma. I was thinking I was correct when I emailed the optometrist that I needed a complaint dx that 401.9 did not justify medical necessity for payment on the claims.
Logged
Medical Billing Forum
Re: Denial-0ptometry
«
Reply #9 on:
September 01, 2010, 02:25:12 PM »
DMK
Hero Member
Posts: 680
Re: Denial-0ptometry
«
Reply #10 on:
September 02, 2010, 02:13:19 PM »
Just to help further my education, does the OD need a referral from the PTP to get this paid? In our line, for example, the PTP must order any x-rays, MRI, CT's in order for Medicare to pay.
Logged
Pay_My_Claims
Guest
Re: Denial-0ptometry
«
Reply #11 on:
September 02, 2010, 02:54:46 PM »
what is a ptp??
Logged
DMK
Hero Member
Posts: 680
Re: Denial-0ptometry
«
Reply #12 on:
September 02, 2010, 07:37:23 PM »
Primary Treating Physician
Logged
Pay_My_Claims
Guest
Re: Denial-0ptometry
«
Reply #13 on:
September 02, 2010, 11:51:43 PM »
thats new on me, never heard that term *writes it down*
Logged
Michele
Administrator
Hero Member
Posts: 5927
Re: Denial-0ptometry
«
Reply #14 on:
September 04, 2010, 02:44:37 PM »
No referral is needed for Medicare to pay for an eye exam for a medical reason.
Logged
Sign Up for our FREE
Medical Billing Newsletter
Get a 10% discount on
Medical Billing Products
by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com
Medical Billing Forum
Re: Denial-0ptometry
«
Reply #14 on:
September 04, 2010, 02:44:37 PM »
Print
Pages: [
1
]
« previous
next »
Medical Billing Forum
»
Coding
»
Coding
(Moderators:
Alice Scott
,
Michele
) »
Denial-0ptometry