I do billing for a Pain Dr and we do TF Injections 64483 under MAC Anesthesia 01935 and Facet injections 64493 also under MAC Anesthesia 01935. We bill the procedure under the Dr and the MAC under the CRNA. I have no problem getting paid by MCR, BCBS, Aetna and Cigna but Human and UHC will deny either the procedure or the MAC as "Unbundled service". Stating per MCR CCI edits 01935 has an unbundle relationship with 64483 or 64483 has an unbundled relationship with 01935.
I have look up the edit on CMS.gov and it basically states that with limited exception Anesthesia is not paid separately unless the procedure is preformed by the Dr and the Anesthesia is preformed by the CRNA, It also states under the MAC section that if found medical necessary MAC is separately reimbursable.
I found the the following on the UHC website under Reimbursement policies CCI edits the following :
Reimbursement Guidelines
Medicare NCCI edits
UnitedHealthcare uses this policy to administer the "Column One/Column Two" National Correct Coding Initiative (NCCI) edits not otherwise addressed in UnitedHealthcare reimbursement policies to determine whether CPT and/or HCPCS codes reported together by the Same Individual Physician or Other Health Care Professional for the same member on the same date of service are eligible for separate reimbursement. When reported with a column one code,
UnitedHealthcare will not separately reimburse a column two code unless the codes are appropriately reported with one of the NCCI designated modifiers recognized by UnitedHealthcare under this policy. When one of the designated modifiers is appended to the column two edit code for a procedure or service rendered to the same patient, on the same date of service and by the Same Individual Physician or Other Health Care Professional, and there is an NCCI modifier indicator of ?1?, UnitedHealthcare will consider both services and/or procedures for reimbursement. Please refer to the ?Modifiers? section of this policy for a complete listing of acceptable modifiers and the description of modifier indicators of ?0? and ?1?.
And in the UHC Anesthesia policy it also states that a mod is aloud for reimbursement of both codes.
https://www.unitedhealthcareonline....FilesHtml/ReimbursementPolicies/CCI_2014B.pdf
So I guess my question is am I aloud to bill 01935 with a mod 59 even though we are billing the procedure and Anesthesia under different providers? Is anyone else have this same issue?
I am not questioning the codes we are billing I am just trying to find out how to get UHC and Humana to pay these claims without bundling them since they say they follow MCR guidelines but MCR pays our Procedure and Anesthesia claims with no problems.
UHC and Humana deny some claims and pay others. Sometimes the MAC denies and sometimes the primary procedure denies.
Thank you for any help
Also if it helps to know we bill the Procedures and the anesthesia on separate claims
I have look up the edit on CMS.gov and it basically states that with limited exception Anesthesia is not paid separately unless the procedure is preformed by the Dr and the Anesthesia is preformed by the CRNA, It also states under the MAC section that if found medical necessary MAC is separately reimbursable.
I found the the following on the UHC website under Reimbursement policies CCI edits the following :
Reimbursement Guidelines
Medicare NCCI edits
UnitedHealthcare uses this policy to administer the "Column One/Column Two" National Correct Coding Initiative (NCCI) edits not otherwise addressed in UnitedHealthcare reimbursement policies to determine whether CPT and/or HCPCS codes reported together by the Same Individual Physician or Other Health Care Professional for the same member on the same date of service are eligible for separate reimbursement. When reported with a column one code,
UnitedHealthcare will not separately reimburse a column two code unless the codes are appropriately reported with one of the NCCI designated modifiers recognized by UnitedHealthcare under this policy. When one of the designated modifiers is appended to the column two edit code for a procedure or service rendered to the same patient, on the same date of service and by the Same Individual Physician or Other Health Care Professional, and there is an NCCI modifier indicator of ?1?, UnitedHealthcare will consider both services and/or procedures for reimbursement. Please refer to the ?Modifiers? section of this policy for a complete listing of acceptable modifiers and the description of modifier indicators of ?0? and ?1?.
And in the UHC Anesthesia policy it also states that a mod is aloud for reimbursement of both codes.
https://www.unitedhealthcareonline....FilesHtml/ReimbursementPolicies/CCI_2014B.pdf
So I guess my question is am I aloud to bill 01935 with a mod 59 even though we are billing the procedure and Anesthesia under different providers? Is anyone else have this same issue?
I am not questioning the codes we are billing I am just trying to find out how to get UHC and Humana to pay these claims without bundling them since they say they follow MCR guidelines but MCR pays our Procedure and Anesthesia claims with no problems.
UHC and Humana deny some claims and pay others. Sometimes the MAC denies and sometimes the primary procedure denies.
Thank you for any help
Also if it helps to know we bill the Procedures and the anesthesia on separate claims
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