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Anthem is not paying the claims for CPT codes 64561 (mod 50) and A4290 (Anthem rep told us to change to C1897) with diagnosis code N39.41. The denial from Anthem states THIS PROCEDURE IS NOT PAID SEPARATELY and SERVICE DOES NOT QUALIFY FOR PAYMENT UNDER THE OUTPATIENT FACILITY FEE SCHEDULE. Our office has an ambulatory surgery facility and we have been told by our Anthem representative that our Anthem contract states we are to go by guidelines under COPPS which we have been doing. Anthem is the only payer we have that is denying these claims.
Thanks for your help.
 
By any chance, was the patient on a skilled nursing stay or anything like that?

Just throwing an idea for research out there.

I remember some frustrating times working as a biller when I had denials that made absolutely no sense. It turned out that no one communicated to me that the patient was brought over from an SNF or that the patient happened to be admitted to an inpatient hospital for an unrelated reason on the same day as my service.
 
No the patients were not in a skilled nursing facility or inpatient hospital. Anthem is the only carrier that has denied paying this service.
 
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