Wiki 92583 billed with Dx Z00.129 for Molina SC

[SA91]

Good day all,

Please may someone help/advise regarding this payer scenario? :

We have received a letter from Molina SC stating they want recoup all payments made for the 92583 billed with Dx Z00.129 as the Dx used is not a valid Dx. These services go back as far as 2020 till 2023 (they have paid this with no issue and now the recovery team has reviewed and determined 92583 Dx Z00.129 not valid for audiological services). We bill the 92583 along with our Well Visits. I cannot find any policy on Molina's end nor would they specify which policy/guideline they have used to make this determination. No other payers seem to have and issue with this billing procedure.

Has anyone experienced the same issue with this payer?

Any feedback would be appreciated!

Thank you.

 

[CBLENNIE]

They may be looking for the specific codes for hearing screenings in the range of Z01.10-Z01.118 & Z01.12.

• Z01.10 Encounter for examination of ears and hearing without abnormal findings
• Z01.110 Encounter for hearing examination following failed hearing screening
• Z01.118 Encounter for examination of ears and hearing with other abnormal findings (use additional code to identify abnormal findings)
• Z01.12 Encounter for hearing conservation and treatment

When you search hearing in the ICD-10 index it does state "hearing examination infant or child (over 28 days old) Z00.129. However, we all well know that payers will make their own rules regarding how things should be coded even if it goes against the official guidelines of a given code set. So, Molina may have decided that while according to ICD-10 it is appropriate to use Z00.129 for an infant or child, they want the codes from the hearing exam range Z01.1-Z01.118 & Z01.12.

I work for a commercial insurance company on the opposite side of the country so I have absolutely no experience with Molina SC, you might check with your local (or any chapters in SC) to see if they have any experience with this issue and can shed some light on it for you.

Or you may have to bite the bullet and contact Molina to ask them why they are retroactively adjusting claims to recoup payments made for these services when they are billed with the appropriate ICD-10 code per the coding guidelines.

 

[SA91]

They may be looking for the specific codes for hearing screenings in the range of Z01.10-Z01.118 & Z01.12.

• Z01.10 Encounter for examination of ears and hearing without abnormal findings
• Z01.110 Encounter for hearing examination following failed hearing screening
• Z01.118 Encounter for examination of ears and hearing with other abnormal findings (use additional code to identify abnormal findings)
• Z01.12 Encounter for hearing conservation and treatment

When you search hearing in the ICD-10 index it does state "hearing examination infant or child (over 28 days old) Z00.129. However, we all well know that payers will make their own rules regarding how things should be coded even if it goes against the official guidelines of a given code set. So, Molina may have decided that while according to ICD-10 it is appropriate to use Z00.129 for an infant or child, they want the codes from the hearing exam range Z01.1-Z01.118 & Z01.12.

I work for a commercial insurance company on the opposite side of the country so I have absolutely no experience with Molina SC, you might check with your local (or any chapters in SC) to see if they have any experience with this issue and can shed some light on it for you.

Or you may have to bite the bullet and contact Molina to ask them why they are retroactively adjusting claims to recoup payments made for these services when they are billed with the appropriate ICD-10 code per the coding guidelines.

Thank you for advising on this!

Yes we are have looked in to the other appropriate Dx for the visits.

We have reached out to two different reps from Molina SC and they cannot pin point what policy or guideline they are referring to with no luck on any explanation. We have reached out to our provider rep hopefully to get a more accurate answer so we can address this moving forward with future claims for Molina.

We just have not seen any other payers with similar issue unfortunately it just makes it hard to come up with a clear solution other than disputing with this payer.

 

[CBLENNIE]

I hope your provider rep will have some helpful information for you.

Have you tried submitting a claim for this CPT code with one of the hearing screening DXs to see how Molina processes the claim. Maybe you'll find they will pay the claim with one of these DXs, of course use the one appropriate to the patient's medical record.

If it works maybe, you can look at changing your current process for claims going forward and then see if you can submit corrected claims for the claims Molina has adjusted to recoup their previous payments and see if you can get the payments back from them.

 

[SA91]

I hope your provider rep will have some helpful information for you.

Have you tried submitting a claim for this CPT code with one of the hearing screening DXs to see how Molina processes the claim. Maybe you'll find they will pay the claim with one of these DXs, of course use the one appropriate to the patient's medical record.

If it works maybe, you can look at changing your current process for claims going forward and then see if you can submit corrected claims for the claims Molina has adjusted to recoup their previous payments and see if you can get the payments back from them.

Our provider rep just got back to us and had no other info on this unfortunately.

You are right, we can try the other Dx and keep an eye on those claims we just do not want a recoupment letter coming back to us after 3 years again that is the issue I have.

We can try and submit corrected claims if not pass TF that is something to also consider thank you!

The only LCD article I can find is this A57434 : Vestibular and Audiologic Function Studies where 92583 is in group 8 and the Z01 codes do not show as appropriate at all ?

 

[CBLENNIE]

Is the Molina plan a Medicare Advantage plan, or a dual special needs plan, or a medicaid plan, or is it all of the above. I was guessing it was Medicaid since that is mostly what Molina does and I figured these screenings are for children based on the DX you stated you had been using.

If it is not a MA plan or a dual special needs plan and is just Medicaid plan and you are seeing peds patients, maybe check with your state's Medicaid agency (mostly likely on their website in a provider handbook or manual) to see if they have any specific guidelines for billing hearing screenings for kids. It could be where the guideline that they are not covered with this diagnosis is coming from and Molina may've been processing your claims to pay in error, and they were caught by Medicaid as allowing non-covered DXs for this CPT code.

This would result in Molina retroactively denying these claims and recouping the payments. I don't know if SC has this type of information available for providers or not, but it is another avenue to pursue. Just a thought...

 

[SA91]

Is the Molina plan a Medicare Advantage plan, or a dual special needs plan, or a medicaid plan, or is it all of the above. I was guessing it was Medicaid since that is mostly what Molina does and I figured these screenings are for children based on the DX you stated you had been using.

If it is not a MA plan or a dual special needs plan and is just Medicaid plan and you are seeing peds patients, maybe check with your state's Medicaid agency (mostly likely on their website in a provider handbook or manual) to see if they have any specific guidelines for billing hearing screenings for kids. It could be where the guideline that they are not covered with this diagnosis is coming from and Molina may've been processing your claims to pay in error, and they were caught by Medicaid as allowing non-covered DXs for this CPT code.

This would result in Molina retroactively denying these claims and recouping the payments. I don't know if SC has this type of information available for providers or not, but it is another avenue to pursue. Just a thought...

Yes, correct this is Molina SC MCD only (sorry I thought I put in my initial post that we are a pediatrics office ).

Great idea! Thank you for that insight I am researching SC MCD manuals and policies to see if anything comes up for EPSDT for MCO (there seems to be a section on the state's web page; fingers crossed!)

I will post an update hopefully soon!