Wiki Billing Denial for U/S with Humana Insurance

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lewisbr

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Hi has anyone experience denials from Humana insurance all types tradition and medicare replacement plans when an injection 20610 is billed in conjunction with Ultrasound Guidance Needle 76942. Humana said that it is "filtered" with 20610, I assuming they meant bundled and referred me to the website for the policy, however no such documents have been found of this policy change. Is anyone else experiencing this issue. I have appealed all claims, but any help is appreciated.

thanks
 
Just wanted to share this article. We have stopped billing for the guidance for some carriers like Humana as they don't consider it medically necessary for injection for an easily palpable anatomical area like a large joint.

http://www.aaos.org/news/aaosnow/jul13/managing2.asp

Although reporting code 76942 with the joint injection code 20610 is permissible, many payers are denying this service as not medically necessary.

For example, under the Florida First Coast Medicare local coverage determination (LCD) 29307, ?Imaging procedures performed routinely for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient?s affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.?

Other Medicare carriers, such as National Government Services, have initiated payment recoupments for CPT code 76942 on the basis of lack of medical necessity.
 
OCD, as usual thanks for sharing your wealth of information. I remember you mentioning this before and since one of our providers is with NSG and performs both these procedures for SOME patients, am expecting that sooner or later we'll be experiencing similar denials and/or recoupment requests. Let the appeals begin!
 
thank you both for the feedback because I was not finding this information anywhere I wanted to have something concrete so I can present to the physicians.

thanks again
Brigitte, CPC
 
We are starting to see denials from Humana now too. I had heard at one time adding mod 59 would work, but I don't think that it really applies. Trying to educate my physicians too.
 
76942

Our office has been told by Humana and Aetna the service won't be paid. UB Orthopaedics & Sports Medicine wrote an article stating that at least one of the following is needed for medical necessity:
Hx of server trauma which would derange the normal architecture of the joint
Rheumatoid dz, lupus, gout, etc
Failure of the inital attempt of a knee joint injection
Size of the knee due to BMI >30 or disease process
Aspiration of a Baker Cyst

This Month's Ortho Pink Sheet addressed it too.

Of course in 2015 there are new codes 20604 20606 20611 that will incl. 76942. What the carriers will require to pay these codes remaiins to be seen, but they will be saving money on reimbursement with these new codes.

Suggest you give your physicians a heads up!!
 
20551/2052 with 76942 Denials by Humana

I have had Humana deny my claims as well in 2016 stating they can't be billed together and we need to write it off. After some research and speaking to multiple reps at Humana and finally a claims manager they found that this cpt code combo was in fact being denied in error. Now I have multiple claims that need reprocessing. Just did this last week so I will know in about 30 days if they actually will pay. Keeping my fingers crossed.

I will let you all know of the outcome soon. :D
 
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