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Wiki Query regarding LCD

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Teetertotters

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Hello,

Can someone please help me understand how to properly send a provider query regarding an LCD, without leading the provider? For example, if a provider codes CPT 90792 and you notice that there is an LCD for this code, however the diagnosis codes documented are not on the LCD. How would you handle that while reviewing the coding? Would you send a query to the provider before you submit the claim? If so, how do you word that query without leading the provider?
 
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Teetertotters said:
Hello,

Can someone please help me understand how to properly send a provider query regarding an LCD, without leading the provider? For example, if a provider codes CPT 90792 and you notice that there is an LCD for this code, however the diagnosis codes documented are not on the LCD. How would you handle that while reviewing the coding? Would you send a query to the provider before you submit the claim? If so, how do you word that query without leading the provider?
Click to expand...


I'd say something like "Please clarify the reason why this evaluation was performed."

Additionally, I'd also keep an eye out for whether this was affecting multiple patients, or if it was just a one-off. The provider may need education at some point if it turns out to be a widespread issue.
 
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CPT codes: 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847 and 90853.
ICD-10-CM Codes that Support Medical Necessity
Article ID A57520
Article Title Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services

​

 
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Can someone please tell me if an otolaryngologist can bill for CPT's 90832-90838 or can these only be billed by a certain specialty? Also, can these be billed with an E&M visit on same day? Thanks in advance!
 
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I'm having a hard time understanding why an otolaryngologist would be providing psychotherapy services billed with CPT codes 90832-90838, are they truly providing psychotherapy services as defined by Encoder Pro as follows:

Psychotherapy is a variety of treatment techniques in which a physician or other qualified health care provider helps a patient with a mental illness or behavioral disturbance identify and alleviate any emotional disruptions, maladaptive behavioral patterns, and contributing/exacerbating factors. This treatment also involves encouraging personality growth and development through coping techniques and problem-solving skills.​

Are your providers providing treatment of a mental health or substance abuse diagnosis? Do they have the training and skills to provide psychotherapy for a mental health or substance abuse condition?

If your providers are not credentialed with the various payers, you are billing in such a way as to indicate the provider has the training and skills necessary for providing psychotherapy services. The insurance company I work for would likely flag providers with this specialty billing any of the psychotherapy codes, which could result in an audit of the provider. I imagine this would be the case for most payers would have a similar response to receiving these types of claims. Some may actually flat out deny these services as the specialty typically does not provide these services.

Are you by chance really looking for codes to bill for counseling services related to a medical diagnosis the otolaryngologist is treating?
 
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CBLENNIE said:
I'm having a hard time understanding why an otolaryngologist would be providing psychotherapy services billed with CPT codes 90832-90838, are they truly providing psychotherapy services as defined by Encoder Pro as follows:

Psychotherapy is a variety of treatment techniques in which a physician or other qualified health care provider helps a patient with a mental illness or behavioral disturbance identify and alleviate any emotional disruptions, maladaptive behavioral patterns, and contributing/exacerbating factors. This treatment also involves encouraging personality growth and development through coping techniques and problem-solving skills.​

Are your providers providing treatment of a mental health or substance abuse diagnosis? Do they have the training and skills to provide psychotherapy for a mental health or substance abuse condition?

If your providers are not credentialed with the various payers, you are billing in such a way as to indicate the provider has the training and skills necessary for providing psychotherapy services. The insurance company I work for would likely flag providers with this specialty billing any of the psychotherapy codes, which could result in an audit of the provider. I imagine this would be the case for most payers would have a similar response to receiving these types of claims. Some may actually flat out deny these services as the specialty typically does not provide these services.

Are you by chance really looking for codes to bill for counseling services related to a medical diagnosis the otolaryngologist is treating?
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Thank you for your quick response. We have a new physician on staff, just out of residency and he is looking to treat tinnitus patients with retraining therapy and he asked about these codes. I also did not think these codes would be appropriate for the following definitions:
*Tinnitus pitch match (matching the pitch of the of tinnitus with pure tone or narrow band noise).

* Tinnitus loudness match (matching the loudness of tinnitus with pure tone, narrow band, or white noise).

* Tinnitus minimum masking levels.

* Loudness discomfort levels (multi-frequency measurement of the maximal loudness of sound tolerated by the patient).

* TRT counseling ( tinnitus and hyperacusis counseling)

I am trying to find a code that would be acceptable. I was wondering if an unlisted CPT such as 92599 or 99499 would be more appropriate? Our unlisted CPT's submitted usually get denied do you know how I can confirm if the above definitions would be sufficient for billing an unlisted CPT? Thanks so much for your help!
 
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I would suggest checking with the payers this provider is contracted with to determine if these services would be covered. You might have to check with your provider contracting relations representative to for guidance on billing these services. It may be that they could/would amend this provider's contract to allow for billing of these services and it may be that you need to negotiate a specific fee schedule for these services.

If you are going to use unlisted CPT codes you are going to have to put a lot of work into getting the claims paid because you would likely have to provide medical records for the majority of the claims you submit for these services. Also, if you have a high number of claims being submitted with unlisted CPT codes that is likely going to be a red flag to the payer and may put you on the path to being audited. I really encourage you to contact your payers, preferably the provider contracting rep to discuss your provider beginning to offer these services and working with them on how to bill for the services correctly in accordance with the patient's benefits contract and the provider's contract with the payer.

Just from the bit of googling I did, it appears many major insurance companies do not cover TRT, so you are going to have to probably have some serious research to do to make sure your provider is not providing services that won't be reimbursed by the payers.
 
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nicole@ent-sd.com said:
Thank you for your quick response. We have a new physician on staff, just out of residency and he is looking to treat tinnitus patients with retraining therapy and he asked about these codes. I also did not think these codes would be appropriate for the following definitions:
*Tinnitus pitch match (matching the pitch of the of tinnitus with pure tone or narrow band noise).

* Tinnitus loudness match (matching the loudness of tinnitus with pure tone, narrow band, or white noise).

* Tinnitus minimum masking levels.

* Loudness discomfort levels (multi-frequency measurement of the maximal loudness of sound tolerated by the patient).

* TRT counseling ( tinnitus and hyperacusis counseling)

I am trying to find a code that would be acceptable. I was wondering if an unlisted CPT such as 92599 or 99499 would be more appropriate? Our unlisted CPT's submitted usually get denied do you know how I can confirm if the above definitions would be sufficient for billing an unlisted CPT? Thanks so much for your help!
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You would want to look up the tinnitus policy for the payer. Many find it investigational. You would also have to check the payer policies on psychotheray, but as stated above I doubt that would be a correct option.
Example - https://www.bluecrossnc.com/content...ies/commercial/medical/tinnitus_treatment.pdf
"There is no specific CPT code for psychological coping therapy. The CPT codes used may include evaluation and management codes or possibly 96152 or an unlisted code depending on the type of service and provider."
https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=85&ncdver=1&bc=AAAAEAAAAQAA&= (retired but could be other policies out there)

Coding for TRT

What CPT codes do you use for TRT and hyperacusis therapy?
www.audiologyonline.com
 
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amyjph said:
You would want to look up the tinnitus policy for the payer. Many find it investigational. You would also have to check the payer policies on psychotheray, but as stated above I doubt that would be a correct option.
Example - https://www.bluecrossnc.com/content...ies/commercial/medical/tinnitus_treatment.pdf
"There is no specific CPT code for psychological coping therapy. The CPT codes used may include evaluation and management codes or possibly 96152 or an unlisted code depending on the type of service and provider."
https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=85&ncdver=1&bc=AAAAEAAAAQAA&= (retired but could be other policies out there)

Coding for TRT

What CPT codes do you use for TRT and hyperacusis therapy?
www.audiologyonline.com
Click to expand...
Thank You for all of this information. Yes it does seem to be considered investigational by most payers!
 
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