# Medicaid Denials



## cschmidt@gboncology.com (Sep 28, 2012)

When submitting codes 96368 and 96367 for UCH Medicaid, Managed Health Medicaid, and straight Medicaid, we are all of a sudden getting denials for both codes stating that a modifer needs to be applied. When adding 59 to 96368, that wil get paid but not 96367. When adding 59 to 96367, that will get paid but not 96368. 

Wondering if anyone else is experiencing this same issue and how to submit both codes for payment on both codes.

Thanks, Connie


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## astrong3 (Sep 29, 2012)

Hi connie,

Hope this information will be helpful. http://www.mediregs.com

Variance in Medicare payment policies for secondary services increases the need to focus on accurate and consistent listing of all drugs infused along with start time, stop time, and route of administration for each drug as well as the flush or clearing of IV line(s) that occurred between sequential administrations or notation of drugs that have been mixed in a single bag.

The 2006 edition of the AMA's CPT Changes: An Insider's View refers to a sequential infusion as one “in which the lines are flushed after the first [prior] infusion.” An outpatient encounter paid according to the Medicare OPPS guidelines would generate payment of approximately $36* for each secondary or sequential IV infusion as represented by CPT 96367. 

Concurrent administration of multiple substances is reportable only once per encounter regardless of the number of drugs administered simultaneously. The concurrent infusion procedure is represented by CPT 96368 which under the Medicare OPPS is a “packaged service” that is not separately paid in addition to the primary (initial) service.

Below are three scenarios that demonstrate the significant difference in payment for a treatment plan that includes administration of three pre-medications followed by a 1 hour infusion of a chemotherapy agent:

    When each drug is sequentially administered one after the other there would be four reportable services – 96413 X 1 plus 96367 X 3 – for an estimated payment of $296*.
    When drug compatibility allows the three pre-medications to be mixed in a single bag for administration this service is represented by one billable unit of 96367. Again referring to the 2006 edition of the AMA's CPT Changes: An Insider's View, “an infusion consisting of three substances in a single bag is not intended to be reported as three separate infusion services…”
    The payment for infusion services represents the work effort associated with the venous access, administration and line management and is not determined by the number of agents in a bag. Reimbursement for 96367 X 1 would be approximately $36 plus payment for administration of the primary drug (96413) providing a total payment of around $224*.
Working from the same premise for three compatible drugs that are safely administered through the same primary line; consider the simultaneous or concurrent infusion from three separate piggy-back bags. For this scenario reporting concurrent administration of the three pre-medications with 96368 would generate no additional payment; therefore, reimbursement is determined by the primary or initial CPT (in this scenario 96413) for an estimated payment of $188*.

Good Luck


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