Wiki Medicare Injection Changes?

[bparcand]

I am a student and I recently started externing for an orthopedist and he asked me to find out why the following claim was paid by medicare in 2012 but now is being rejected. It was coded as follows:

Dx: 715.96

CPT: 99212-25, 96365-59, 20610-50-59, J1040-59, J2001-59

Apparently the 96365 code is being denied however everything else is being approved.

He says the same thing also is happening when he uses 96372 instead of 96365.

I think he may be testing me. Any help would be greatly appreciated.

Thanks,

Brian

 

[brendalewing]

You should not bill injection fee, 96372, or an iv infusion with a major joint injection.
The 20610 is an injection fee code...
Can not use J2001, as is for IV.. not for joint injections.
NO modifier 59 on J codes.

Correct billing for the codes you have listed are:
99212-25
20610
J1040

We usually bill:
99213-25
20610
J3301 x 4 units

Hope this helps.

 

[britbrit852003]

96365 is for IV infusions of drugs. This does not sound like what he did.

20610 and 96372 are bundled procedures as 20610 is actual injection procedure and you cannot bill a seperate injection with it.

The only way to get the 96372 and 20610 paid for is if one or all of the medications were given intramuscular (IM) in addition to the joint injection.

So the scenario would be provider injected large joint (20610) with lidocaine (not billable) and then he also gave the J1040 in his arm or intramuscular. In this case you can bill the 96372 and the 20610 with a modifier 59 on the 96372 only.

This claim should look like this:
99212-25, 20610-50, J1040

Cannot bill for lidocaine in this case

 

[vmayor]

Re: Medicare Injection Changes

Dear Brian,

Without the documentation I can only assume he did an arthrocentesis. The 96365 is an infusion code, and the 96372 is an administration code for a diagnostic injection. IF Medicare paid this exactly the way you show you just got lucky. They could recoup at a later date if records don't demonstrate all those separate procedures.

The 20610 code is the injection/aspiration of a major joint. It includes the administration. Therefore, all that should be billed is 99212-25, 20610-50, J1040. That's it. Even the lidocaine J2001 is bundled into the procedure. The only modifier necessary is the 25 and 50 if it was bilateral.

Medicare pays based on the use of modifiers. If they do a review and check documentation, unless something else was done, like an infusion procedure for something else they would ask for the money back.

Good luck.... VM