Wiki Electrophysiology Coding/Billing Experience

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cvand1972

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I'm looking for someone who can help me with this situation. I've got a denial based on a Medicare NCD that I cannot find and I'm hoping someone can maybe enlighten me as to where this insurance company is getting their information.
We are physician office. One of our EP doctors performed some services on an Inpatient at one of our local hospitals. CPT codes billed are:

93651 - paid
93620-26-51 - denied against Medicare NCD that I cannot find
93621-26 - denied; same reason
93623-26 - denied; same reason
93613 - denied; same reason

I see some information pertaining to an APC, but that doesn't pertain to physician, right?? Or maybe I am wrong.
 
Try not using the 51 modifier. I never bill with it.

Did you send chart notes? We bill the same codes all the time and haven't received a denial for NCD. Who is your carrier? We have Noridian.
 
denied ep study

What is the DOS? I am wondering if it is denied because of this CCI edit.

CCI version 16.0, effective Jan. 1, added edits preventing you from receiving payment for recording, pacing, and EP studies performed on the same date of service as an intracardiac catheter ablation . This was deleted but not until April 1st.
 
DOS is 6/4/10. I did see that edit issue also when I was doing research on this. I'll have to try it without the 51 modifier. I will also shed some light on the fact that the CCI edit was deleted. Maybe they aren't updated. But I can't even find that out because everyone I call says 'I can't help you'. Nice.
Our carrier is NGS Medicare. The insurance that is denying this is Secure Horizons, which is a Medicare Advantage Plan administered by United Health Care.
 
Secure Horizons/UHC might be the problem. There have been lots of problems, of late, with receiving payments from UHC. Check with others in your area and specialty. You might be surprised with what you find out.

I would definitely appeal. If you have to, I would talk to the Medical Director for your area. Don't hang up without his/her name and phone number.
 
now im wondering why you would put modifier 58 on every ablation? staged or related procedure by same physician during a post op period? We have always just billed as is no modifiers. But UHC does deny alot of different odd things. I wonder if you should print out CCI edits proof and send a letter and appeal.
 
I was getting denied for all being done on the same day and yes UHC and Secure Horizons being the worst. I appealed, sent the documentation and 59 on the EP study and got paid. So I started putting the 59 on the EP study and I get paid all the time.

Hope this helps
 
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