Wiki co mgmt claim denials

[stacigadsby]

I have started getting denials from Medicare and a United Healthcare Medicare replacement for co management of cataract surgeries. We bill with the -55 modifier and POS 11.

The denial message is that "The Centers for Medicare and Medicaid Services has identified certain procedures that are rarely or never performed in a non-facility setting."

Anyone else getting these? Anyone who understands billing knows that the post-op care is nearly always going to take place in the office.

 

[mzkandyd]

Your codes have to match apples to apples with the surgeons codes. I require that my MD offices send a copy of the claim to my OD's before the OD's can submit the claim.

Make sure your MD/Surgeon used the correct modifier on their claim to allow you to bill for the post operative period. Sounds like they may have left it off and now the payor is thinking your trying to bill a surgery with POS 11.

 

[mitchellde]

Also be sure to use the V code for either post op aftercare or follow up as the dx code, do not code the cataract since it does not exist.

 

[stacigadsby]

Debra, are you sure about that? I was always told like Kandy said that our codes had to match theirs, so I've always billed it with whatever cataract diagnosis the surgeon gives me.

 

[mitchellde]

Debra, are you sure about that? I was always told like Kandy said that our codes had to match theirs, so I've always billed it with whatever cataract diagnosis the surgeon gives me.

I am 1000% sure. The procedure must match the surgeons, but the diagnosis is the patient's and must reflect the patient at the time of the visit. It is either aftercare or follow up , as there is no longer a cateract.

 

[mzkandyd]

Debra is correct! You have to match the other providers codes, HOWEVER, the patient no longer has the cataract so the V43.1 is appropriate. I second Deb's 1000% assurance!