Wiki 99204-25

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amym

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We have recently started encountering denial from Medicaid for CPT 99204-25 when billed same day as nuclear stress test 78452, 93015. The denail reason is "5927 THIS PROC IS CONSIDERED INCIDENTAL TO ANOTHER PROC BILLED ON A HISTORY CLAIM". Is this accurate? We've never had this issue before.
 
If the stress test was already scheduled, even if the patient is a new patient you cannot charge the visit level since the evaluation to determine the necessity for the procedure was already done, even if by another physician they are not inclined to pay for this twice. Rarely are tests like a nuclear stress test performed immediately after examining the patient, they are almost always scheduled ahead of time. If you have the rare instance where the provider is seeing the patient for the first ime and makes a determination at that time a test is needed and it cannot wait to be scheduled then you can appeal with this information.
 
If the patient is referred to you for the purpose of the test then there is no way for you to bill for an initial office encounter. If you are seeing the patient for a problem and then determine that the test is necessary then you do not need to bring them back just appeal with the information that this was not a prior scheduled test.
 
The only time I have seen that denial is when a patient is established and not a new patient. 99204 is for new patient visits only. Make sure patient is not established and if so, change 99204 to 99214. That denial is related to the office visit code and not the stress test most likely.

Simone CPC, RHIT
 
Your next question is what is the limit amount of stress test Medicaid would cover. I checked with our OBGYN facility today and sure enough, that is the same denial that is received when a Mcaid patient has reached its maximum amount of ultrasounds. Two were billed prior which is the incidental found on a history claim.
Simone
 
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