Wiki AARP MEDICARE COMPLETE OT Evaluations

[apoland]

Hi,

I have a patient who was seen in OT for therapies relating to CTS. AARP MEIDCARE COMPLETE denied stating not medically necessary. They original claim did not have quality codes present, but I have since rebilled and received the same response. Anyone seen this happen? The MEDICARE LCD states that CTR is a medically necessary diag for OT evaluations...

Thanks!

 

[honeybee]

I work in PT/OT and we have never needed to include functional reporting or PQRS codes to claims for this plan, unless its just a very very new edit. Have you tried calling to get more info or see if its just a mistake or maybe there is an issue with needing auth or something else going on?

 

[apoland]

I did try calling, but of course I don't get to speak with the claims analyst just a rep, who parrots back what the denial states. I can't seem to get any where..
Thanks =)

 

[honeybee]

Figures, I hate when the reps do that! Are you using the GO modifiers? Could that be the problem. I cant think of anything else that could be an issue

 

[mhstrauss]

Just taking a stab in the dark at this...but could the patient possibly have been over a therapy cap? I know not all payers have the exact same limits that traditional Medicare has, but most have some type of guideline. Just a thought!