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awhite@galaxybraincenter.com

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we billed Federal BCBS 97129/ 97130 with dx code R41.841 ( cognitive code) got denial not covering cognitive service. what can i do in this situation? or what can i do before hand so this doesnt happen. can i rebill with CPT code 92507 with Aphagia R47.01? or is that not allowed. can i look at something differently when verifying benefits? i am new to this and want to make sure i'm doing all the right things. any help is appreciated. thank you so much. :)
 
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awhite@galaxybraincenter.com said:
we billed Federal BCBS 97129/ 97130 with dx code R41.841 ( cognitive code) got denial not covering cognitive service. what can i do in this situation? or what can i do before hand so this doesnt happen. can i rebill with CPT code 92507 with Aphagia R47.01? or is that not allowed. can i look at something differently when verifying benefits? i am new to this and want to make sure i'm doing all the right things. any help is appreciated. thank you so much. :)
Click to expand...

Payers will often have a specific Clinical Policy on the website listing any medical necessity requirements. Cognitive Rehabilitation specifically will often have a list of medically necessary conditions and a list of excluded conditions. When you're verifying benefits, it will be very important to verify whether it is covered for the patient's specific diagnosis.

BCBS Federal has a policy on the website stating that it may be considered medically necessary for patients with cognitive impairment due to traumatic brain injury. It is considered investigational for all other applications.

Here's a link and screenshot from that BCBS Federal policy so you have it for reference:


1726770260950.png

Some other links you may find helpful for future use:

ASHA (American Speech-Language-Hearing Association) Coding and Payment of Cognitive Evaluation and Treatment Services: https://www.asha.org/practice/reimb...-cognitive-evaluation-and-treatment-services/

BCBS Michigan and Blue Care Network medical policy on Cognitive Rehabilitation. Specific details on the inclusions and exclusions are stated on page 2 of this PDF: https://www.bcbsm.com/amslibs/content/dam/public/mpr/mprsearch/pdf/76784.pdf
 
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sls314 said:
Payers will often have a specific Clinical Policy on the website listing any medical necessity requirements. Cognitive Rehabilitation specifically will often have a list of medically necessary conditions and a list of excluded conditions. When you're verifying benefits, it will be very important to verify whether it is covered for the patient's specific diagnosis.

BCBS Federal has a policy on the website stating that it may be considered medically necessary for patients with cognitive impairment due to traumatic brain injury. It is considered investigational for all other applications.

Here's a link and screenshot from that BCBS Federal policy so you have it for reference:


View attachment 7370

Some other links you may find helpful for future use:

ASHA (American Speech-Language-Hearing Association) Coding and Payment of Cognitive Evaluation and Treatment Services: https://www.asha.org/practice/reimb...-cognitive-evaluation-and-treatment-services/

BCBS Michigan and Blue Care Network medical policy on Cognitive Rehabilitation. Specific details on the inclusions and exclusions are stated on page 2 of this PDF: https://www.bcbsm.com/amslibs/content/dam/public/mpr/mprsearch/pdf/76784.pdf
Click to expand...
THANK YOU SOOOO MUCH!!!!
 
0
sls314 said:
Payers will often have a specific Clinical Policy on the website listing any medical necessity requirements. Cognitive Rehabilitation specifically will often have a list of medically necessary conditions and a list of excluded conditions. When you're verifying benefits, it will be very important to verify whether it is covered for the patient's specific diagnosis.

BCBS Federal has a policy on the website stating that it may be considered medically necessary for patients with cognitive impairment due to traumatic brain injury. It is considered investigational for all other applications.

Here's a link and screenshot from that BCBS Federal policy so you have it for reference:


View attachment 7370

Some other links you may find helpful for future use:

ASHA (American Speech-Language-Hearing Association) Coding and Payment of Cognitive Evaluation and Treatment Services: https://www.asha.org/practice/reimb...-cognitive-evaluation-and-treatment-services/

BCBS Michigan and Blue Care Network medical policy on Cognitive Rehabilitation. Specific details on the inclusions and exclusions are stated on page 2 of this PDF: https://www.bcbsm.com/amslibs/content/dam/public/mpr/mprsearch/pdf/76784.pdf
Click to expand...
So rebill with CPT code 92507 with Aphagia R47.01 will be ok right?
 
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awhite@galaxybraincenter.com said:
So rebill with CPT code 92507 with Aphagia R47.01 will be ok right?
Click to expand...


The codes billed have to accurately reflect the service performed and documented.

The ASHA link that I posed above has the following statement:

1726771969848.png

Going by that ASHA statement, if I were in your shoes, I would review the documentation and also clarify with the clinican to determine whether that patient's services could be appropriately represented with 92507.

I can't say for certain, because I'm not looking at the patient's documentation. (It has also been many, many years since I've billed PT/OT/Speech!)

You'll also need to make sure that the diagnosis code you bill is substantiated by the documentation.

Good luck!
 
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