Billing > Billing
CO-45 denial - getting paid nothing
BWB:
It was 99213 and 64640. And it was BC/BS.
Merry:
http://downloads.cms.gov/medicare-coverage-database/lcd_attachments/30153_18/L30153_MS007_CBG_010112.pdf
I just found this link..Was the injection for tarsal tunnel or Morton's neuroma. They are addressed here.
On the other hand, wouldn't you use -25 modifier
Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
RichardP:
See this take on 64640 from Blue Cross/Blue Shield of Florida:
http://blueline.staywellsolutionsonline.com/Past/Winter2010/22,Wi10BC2
And this question and answer, from here:
http://www.podiatrym.com/search3.cfm?id=6422
Q: A patient was seen in our office for pain 3rd interspace right foot. An ultrasound confirmed the presence of a neuroma. In the office, the patient was given sclerosing nerve injections (CPT 64640) to the interspace at intervals of every 10 days for a series of 6 injections.
The insurance company denied the claims stating "surgery performed in the office" is not a covered benefit. I have appealed to the insurance company stating this is an injection that was given in the office, and not an open, cutting procedure. Any suggestions would be helpful.
A: Codingline Response: On the issue of the payer denying your office "procedure", CPT is divided into sections: E/M, Surgery, Pathology and Laboratory, Medicine, etc. The injection you are referring to "resides" under "Surgery" (along with cutting toenails and applying a cast). So, if this patient's insurance plan benefit structure language excludes ALL in-office surgery [coding] from reimbursement, then the insurance company's denial of your claim is correct, and you may only be left with charging the patient.
PMRNC:
Sure hope we are looking at the chart documentation first.
RichardP:
This comment could be viewed as nit-picking. I view it as "clarification". :D
Looking at the chart documentation should tell the doctor or coder whether they are sending the proper coding to the Insurance Carrier. But looking at the chart documentation won't tell them anything about why the Carrier is paying nothing on the code. The Insurance Carrier is in no position to claim/prove that the chart documentation does not support the code - as this situation is not an audit. So looking at the chart cannot help the doctor or coder understand why the carrier is paying nothing.
However, if BC/BS is claiming that this code falls under the "Surgery" category, and if this patient does not have coverage for surgery ...
I don't think anybody here is trying to solve her problem for her. Rather, we are providing some information through which she can learn some possible reasons why BC/BS might be paying nothing on this particular code - beyond what you have alread said. She did say she was new to this.
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