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rjh977@vc

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Does anyone have any advice on the following? Pt had base of tongue/tonsil cancer and finished treatment in 2017. Pt comes in for follow-up, physician does scope (31575) to make sure everything is good and no new growths. We bill the scope with a history of code and Humana ALWAYS denies it. The office visit gets paid but not the scope. Since it has been 2 years since the patient's cancer was in active treatment, should we only bill the office visit?

Thanks for any and all help!!!

RHutchens
GKENT
 
Hello rjh977@vc,

There are edits when an e/m is billed with CPT 31575. I recommend checking the Humana policy for CPT 31575 as the DX you are billing may not meet their medical necessity criteria. If the patient is presenting for the scope as the check up than only CPT 31575 should be billed. If the patient was scheduled for an office visit (history or exam and MDM documented)and the provider decided to perform the scope than you should bill the e/m with modifier 25.
 
Thank you for responding. The patient was only here for a check up. So i might need to educate my physicians that if the patient is only here for a recheck to make sure everything still looks good, then they should only bill the scope- use dx codes z08 and the hx code? But if they find something else then they can bill the office visit with modifier -25 and the scope. Humana just denies our hx codes on the scope as "invalid dx for the procedure" no matter how we bill it..... That's what i can't figure out.

Again, thanks for the help-it is very much appreciated!!

Becky hutchens
gkent
 
rjh977@vc said:
Thank you for responding. The patient was only here for a check up. So i might need to educate my physicians that if the patient is only here for a recheck to make sure everything still looks good, then they should only bill the scope- use dx codes z08 and the hx code? But if they find something else then they can bill the office visit with modifier -25 and the scope. Humana just denies our hx codes on the scope as "invalid dx for the procedure" no matter how we bill it..... That's what i can't figure out.

Again, thanks for the help-it is very much appreciated!!

Becky hutchens
gkent
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You're welcome :)
 
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