Wiki Denials for routine codes

Create Wiki
A

ajimenez

Contributor
Messages
12
Location
Tucson, AZ
Best answers
0
Hello my fellow coders out there I need some help here asap. I'm having a problem with APIPA and Unided Healthcare denying claims for pt over 20 with routine codes on them (367 series) and I was wondering if anyone is having or has had the same problem and if so how was it resoved (if resolved)? I have over 100 claims that have been denied because of this. My reimbersment coordinator is telling me not to linke them to the office visit and if the the pt gets glasses only link them to the 92015 refraction code. I don't think that is correct coding if I don't link the routine dx to the office visit too. I can really use some advise here it would be greatly appreciated.

Thanks Annette
 
If your patients are coming in for routine visits then your dx codes need to be V codes. 367 series denotes a "problem" and will adjudicate as such.
 
They are coming in for medical dx and just so happens to have a routine dx also. I know if they come in for routine and routine only that they are selfpay because the insurance won't cover the routine codes. Sometimes we give the refraction and sometime we don't because the pt doesn't want it. If I bill with the routine in the second place or third but the medical dx is first postion then United healthcare and APIPA denies the claim.
 
Do not put any routine dx on the claim if you have a medical dx - also, they want to see that's it's a corrected claim if you rebill. I make sure there is a #7 in box 22 on the HCFA and I put the ICN of the original denial. I do this for United Healthcare and my claims get paid
 
If you are coming in for a "medical problem" there is no there so happens to be a routine dx. If the patient is coming in for their annual vision exam, then your dx code should be V72.0, plus any other findings. If your patient is coming in for a problem such as KCS, Dry Eyes, Keratoconus, etc. then there is no V72.0 (routine dx).
 
The 367 codes are for refractive diagnoses and are not paid for by major medical or Medicare in the majority of cases. They should only be linked to the 92015 refraction code.

You can bill for an E/M code and have a medical diagnosis attached to that and still have the 92015 code with the 367 refractive codes linked to it and the insurance companies will pay for the E/M service and deny the 92015 which is OK.

You should collect the 92015 fee from the patient at time of exam, since it is never paid by Medicare nor hardly any of the major medical plans, and when the patient sees their EOB with the denial for the 92015 won't be calling you asking for that fee to be refunded.

If your office isn't charging and collecting for the 92015 fee at time of exam, they are literally throwing tens of thousands of dollars in legitimate fees out the window each year.

Tom Cheezum, O.D., CPC-A
 
You must log in or register to reply here.
Top