Wiki denial on either professional or facility claims

[skiboi]

Hello I do the coding and billing for a pain management clinic, we do spinal injections and that is where I'm inconsistently seeing denials for example on CPT code 62323, when I bill this professionally and facility with an SG modifier to designate service performed in an ASC. Payers are finding a myriad of denials to apply to either billing.

I have adopted, across the board and as we all know every payer is different and they all adapt there own rules. This may take further investigation on my part to figure this out per payer. But overall I'm seeing a huge denial rate and wanted to find out whether others that are billing both pro & fac claims are having the same issues and denial rates?

For example I would bill 62323 for pro claim with POS 24, I would bill 62323-SG with POS 24 I've seen denials come back for units bumping up against the authorization that is only good for one unit. Applying multiple procedure reason codes and then pay nothing for either or Px submitted, the list goes on.

Feedback and moan and groans for the same problem would be appreciate. Thank you and have a great weekend.

 

[thomas7331]

A few of things I would ask off the top of my head to start with: Is your clinic a licensed facility and credentialed with the payers as a facility? If so, have they set you up with two separate provider numbers (one for the physician and one for the facility) and are you billing the claims under the different provider numbers so they are distinct and distinguishable by the payer? And are you billing the facility charges on the correct form per the payers guidelines? (In my experience, many payers no longer accept the facility charges on a 1500 form with the SG, unless it is specified in the contract, and would be looking for a UB-04 claim.) If the answer to any of these questions is no, then the payer systems may not even be recognizing those charges with the SG modifier as facility charges and that could be a part of your denial problems.