Medical Billing Forum
Coding => Coding => : mtlopez March 28, 2019, 05:32:38 PM
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I would like some help regarding this CPT code 92558, as a pediatrician we use this code for Otoacoustic Emissions (OAEs) according with the machine we use, but he insurances denied the claim, they said is not payable, they just only pay it when pt has any hearing problem, not as a part of annual physical.
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I would need more specific information in order to help. What is the denial code? Also, is the dx routine?
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Medicare itself won't cover the 92558 but may cover the other two (92587, 92588) but with hearing problems. I've billed this with some success using the 33 modifier and then some carriers flat out deny it. We verify benefits on these. If it's a patient covered under an ERISA health plan and carrier tells us it's not covered unless it's hearing problem related, we ask patient to sign an ARF and give us a copy of their SPD as that would take precedence over carrier rule. With ERISA it's a really good bet this is not in their plan as "non covered" but rater might be denied as "not medically necessary" to which an ERISA appeal could be succesful
A first level appeal would be letter stating that the patient's plan (SPD) does not exclude this service and then documentation should be provided to show why the test was performed and the patien'ts plan benefit regarding routine and/or annual visits. I get almost ALL of these overturned on first appeal. A 2nd appeal under ERISA requires the provider to show HOW they determined the physician's services were NOT appropriate meaning they must provide and name all the credentialed personnell and medical providers used to make their determination. When I do a first appeal I always include that part of ERISA in my letter so that they are aware of what THEY are required to show.
The above only applies to ERISA. Non ERISA (govt /state/church plans will have their own rules and again Medicare doesn't cover the 92558 so Medicaid wouldn't either most likely.)