Wiki HELP!!! OPTUM - PAIN MANAGEMENT INJECTION DENIALS

[aosborne88]

We have been having an issue of getting our pain management injections paid by Optum Lifeprint (ex. ESI, MBB, RFA, Joint, etc). Everytime we bill an injection, we get a denial stating that Optum requires a drug code to be associated with the claim. And here is the kicker: we don't buy the drugs in bulk and they are billed by the pharmacy. To avoid the pharmacy having any issues, we tried to put a miscellaneous drug code, J3490, with a zero dollar charge, but now they are denying the injection all together and only paying imaging codes. We have not been able to find any policies to explain this and Optum has been reluctant to provide one.

Has anyone else had this issue? How have you ensured payment?

 

[OpenClaims]

If the pharmacy is billing the drug codes, I would think they would set up your EMR to include drug/facility charges for the same encounter on a facility claim. That is what I've always seen facility's doing and we've never had an issue with this.

 

[amyjph]

If you are talking about billing for the physician (ex. physiatrist) performance of the injection, and it is being done in a facility, you shouldn't be putting any drug (J) codes on the claim at all. Your claim would have just the injection such as 644836, 64484. Drugs require NDC codes. Or, are you talking about the facility claim?

 

[aosborne88]

If you are talking about billing for the physician (ex. physiatrist) performance of the injection, and it is being done in a facility, you shouldn't be putting any drug (J) codes on the claim at all. Your claim would have just the injection such as 644836, 64484. Drugs require NDC codes. Or, are you talking about the facility claim?

These are for in office injection procedures. There is no facility charge.

 

[CLICLEMME]

Is it rejecting for a 2410 loop?

 

[mburke81]

We have been having an issue of getting our pain management injections paid by Optum Lifeprint (ex. ESI, MBB, RFA, Joint, etc). Everytime we bill an injection, we get a denial stating that Optum requires a drug code to be associated with the claim. And here is the kicker: we don't buy the drugs in bulk and they are billed by the pharmacy. To avoid the pharmacy having any issues, we tried to put a miscellaneous drug code, J3490, with a zero dollar charge, but now they are denying the injection all together and only paying imaging codes. We have not been able to find any policies to explain this and Optum has been reluctant to provide one.

Has anyone else had this issue? How have you ensured payment?

I am seeing the same denials for 20611 when no medication is billed. My providers inject caines, and I cannot find any policies on this either. The only one found was Anthem VA stating to use J3590. These are done in physician clinic .

 

[amyjph]

Okay if you are talking in office you can see if they have a policy that says to bill the J with a penny charge for informational purposes. It's like their claim system is kicking it out due to an edit that says there must be an associated J code for injection admin. Seems crazy because that rule makes no sense when the 2061_ area is used for aspiration too so there wouldn't necessarily be a J code. Frustrating.

 

[lgardner]

Okay if you are talking in office you can see if they have a policy that says to bill the J with a penny charge for informational purposes. It's like their claim system is kicking it out due to an edit that says there must be an associated J code for injection admin. Seems crazy because that rule makes no sense when the 2061_ area is used for aspiration too so there wouldn't necessarily be a J code. Frustrating.

I agree with Amy's thoughts.

I would appeal the denials, with documentation, for the 2061* codes, if they were aspirations only.
Even if just 'caines were injected. Although if they want the J codes, it wouldn't hurt to add J3490 - unclassified drugs (used for the 'caines), which is usually set at a 0 or 1 cent charge.