Wiki 97799 and 92507

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We have been having issues getting code 97799 paid by aetna and looking for an alternative code. This is for ST and OT for pedi. Currently the only carrier we are having issues with is Aetna. Any advice would be helpful.
 
What is the service being provided that you are billing with 97799-unlisted physical medicine/rehabilitation service or procedure? Are you sending Aetna a description of the services billed with 97799 as well as medical records supporting use of the unlisted code? It can be difficult to get an insurance company to cover an unlisted code even if you do provide this documentation.
 
We are not sending a description. Will this need to be done on the claim form in box 19? We have submitted medical records but still having issues. The services are for speech and OT just regular therapy sessions. The reason why the code has been submitted is due to the low amount of payment for the 92507. I was thinking of using an E/M code to replace the 97799
 
In general, any time you use an unlisted code you should be including a description of the service, whether it is on the claim form or in the medical records. If you are providing the description in the medical records, that should suffice but from an insurance company's perspective it is helpful to have a description of the procedure on the claim form in addition in the medical records.

With respect to your desire to bill 97799-Unlisted physical medicine/rehabilitation service or procedure instead of the existing/defined CPT codes for OT and ST because the reimbursement is too low on those existing codes, this is not appropriate coding. Changing codes for the purpose of increasing reimbursement is a quick way to get your provider on a list of providers to be audited by the payers you are submitting claims to.

Additionally, your OT & ST providers are unlikely to be providing services that qualify for billing E&M codes instead of the appropriate physical medicine/rehabilitation codes and again would not be appropriate if they are not rendering E&M services as defined by CPT. Additionally, most plans have benefit limits for rehabilitation or habilitation OT & ST services and the benefit for these services might be different than the benefits for an office visit E&M.

Just because you are getting other insurance companies aside from Aetna reimbursing you for 97799, don't be surprised if the other companies come back to you in the future after auditing your provider's claims and requesting any overpayments back because of incorrect coding.

Were you directed by your compliance specialist or management about making these coding changes just to receive higher reimbursement than you currently do because if you make this decision on your own you could be liable for any repercussions for knowingly submitting claims with incorrect codes for the purposes of receiving better reimbursement rates. I would tread very lightly in changing how you code claims because someone has decided the existing reimbursement rates being too low for the appropriate and existing CPT codes for OT & ST services, you don't want to be the one left holding the bag and being liable for these decisions if you did not make the decision to use alternative codes to receive better reimbursement rates.
 
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