Wiki Medicare billing - Please help

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Tanna717

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Please help. Where should I start? Working medicare denials. What can help me see what dx are covered and what is not? Working for a primary care, fqhc facility. :confused:
 
medicare billing

The first place to look is the medicare carriers website. there are local coverage determination (LCD's) that explain the different policies for each code. If you can't find what you are looking for there, you can call medicare.
 
first you can log on to ngsmedicare.com website which will tell you about all things Medicare related. you have to click accept to accept terms of site, on the left hand side you want to click on medical policy center (LCD's) once you click that you will enter the procedure code that is being denied ( you can find that on you remit) and enter the procedure code under search for medical policy info if you scroll down the procedure code will be listed with the diagnosis medicare considers Medically Necessary. if your dx on the remit is correct then your denial is not for a dx however if the dx on the remit is not what medicare shows as medically necessary you will need to get permission from the physcian to change the dx then call the reopen line and have the claim reprocessed with the correct dx. hope this helps:)
 
Thank you! What I am getting stuck on is the 'procedures' we are billing: they are just office visits. So when i get a denial for non covered. I want to know why and need information to get to my providers.
 
96-CO96-NON-COVERED CHARGES. Selected: 96-CO96-NON-COVERED CHARGES

MA01-MA01 - MAY APPEAL IF NOT AGREE W/ WHAT WAS APPROVED FOR THESE SVCS. WRITE W/IN 120 DAYS OF NOTICE TO BE ELIGIBLE FOR REVIEW )
 
tsmiddle@nfpmedcenter.org said:
96-CO96-NON-COVERED CHARGES. Selected: 96-CO96-NON-COVERED CHARGES

MA01-MA01 - MAY APPEAL IF NOT AGREE W/ WHAT WAS APPROVED FOR THESE SVCS. WRITE W/IN 120 DAYS OF NOTICE TO BE ELIGIBLE FOR REVIEW )
Click to expand...

Can you give an example of what codes (CPT and ICD-9) that were billed? Helps to know about the whole picture. Also, were there any surgical procedures in the 90 days prior to the office visits? Lots of possible reasons for denials.
 
Sure, some examples of dx used are: these are all billed with a LOS.

1) 854.00-BRAIN INJURY NEC [Active]
2) 435.9-UNSPECIFIED TRANSIENT CER [Active]
3) 345.90-UNSPECIFIED EPILEPSY WITH [Active]
4) 401.9-UNSPECIFIED ESSENTIAL HYP [Active]

or

1) 585.4-CHRONIC KIDNEY DISEASE, S(P) [Active]
2) 401.9-UNSPECIFIED ESSENTIAL HYP [Active]
3) 493.90-UNSPECIFIED ASTHMA [Active]
4) 530.81-ESOPHAGEAL REFLUX [Active]
5) 296.80-BIPOLAR DISORDER, UNSPECI [Active]
 
Medicare billing

What place of service are you billing and what CPT are you billing?
 
tsmiddle@nfpmedcenter.org said:
Sure, some examples of dx used are: these are all billed with a LOS.

1) 854.00-BRAIN INJURY NEC [Active]
2) 435.9-UNSPECIFIED TRANSIENT CER [Active]
3) 345.90-UNSPECIFIED EPILEPSY WITH [Active]
4) 401.9-UNSPECIFIED ESSENTIAL HYP [Active]

or

1) 585.4-CHRONIC KIDNEY DISEASE, S(P) [Active]
2) 401.9-UNSPECIFIED ESSENTIAL HYP [Active]
3) 493.90-UNSPECIFIED ASTHMA [Active]
4) 530.81-ESOPHAGEAL REFLUX [Active]
5) 296.80-BIPOLAR DISORDER, UNSPECI [Active]
Click to expand...

Ok I am not sure what you mean by LOS. What specific CPT code are you using and what place of service are you using? And have there been any surgical procedures in the 90 days prior to this visit that is being denied. The diagnosis codes are fine, so the problem has to be in the CPT code or the circumstances in which the bill is being submitted.
 
tsmiddle@nfpmedcenter.org said:
Level of service code, 99213, 99214 etc..
Click to expand...

Ok. So the CPT and ICD-9 codes are fine. The next avenue to explore is whether or not any of the patients with these denials have had a surgical procedure in the previous 90 days. CMS must be considering the visits "non-covered" for some reason, and that is the next logical assumption. If the patient had a surgery by ANY provider in the previous 90 days all office visits will be considered non-covered, unless you can show the condition is not related to the surgery. Usually that means a modifier is needed. So we need more information surrounding the circumstances of the patient.
 
Call the Medicare contractor! If you see the CO96, look for the other remark codes on the EOB-they usually explain the denial in more detail. (M__ , N___, MA____ ....)
 
hopepg said:
Call the Medicare contractor! If you see the CO96, look for the other remark codes on the EOB-they usually explain the denial in more detail. (M__ , N___, MA____ ....)
Click to expand...

And those codes are usually found under the patient name area of the EOB...sometimes hard to find but they should be there.
 
We would really need the CPTs used to help you with this per ICD code denied. Thanks!
 
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