Wiki VA acupuncture services payment issue with evaluation visit

[Kocob]

Hello, I would like to know if anyone is having the same denial as I have.
Patient with VA approved acupuncture services and 1 unit of initial evaluation is approved within the authorization. However, VA Optum denies the code as non-covered. I use Office visit code normally 99203/99213 or 99204/99214 depending on the evaluation. As far as I know, Acupuncture does not have it's own evaluation CPT code, as in Physical Therapy. I was told I have to file an appeal every time I get denial for the evaluation. Does anyone know the solution for this issue? I am in CCN Region 3. Thank you for your input.

 

[thomas7331]

Medicare only allows certain provider types to bill E&M codes and an acupuncturist is not one of those providers that they recognize. Since the VA usually follows Medicare guidelines pretty closely, I imagine that they would also follow this policy. I don't think it's anything that you can appeal since it is a statutory requirement.

That being the case, you might consider billing an unlisted code for the acupuncture initial evaluation and see if they might consider it payable as a separate service, but my guess is that they will consider the evaluation inclusive to any acupuncture services that are provided.

 

[Kocob]

Thank you for the input. I understand part of the 97810/97813 includes the "o/v" part of the visit for the returning visits, but for the initial and re-assessment, Acupuncturist spend extra time beside the treatment to evaluate the patients. I may need to find the CPT code that could cover that service. Thanks again.

 

[kristy2]

Hello, I am researching VA CCN coding for acupuncture and came across your thread. We are billing 99202-99203 or 99212-99213 for our initial or re-assessments and we have gotten paid without any issues. We do use modifier 25 on the exam line. Are you billing it with a modifier 25?

Also, we are having issues with our 97811 code. Our visits are 60 minutes and we are billing as 97810 for the first 15 minutes and 97811 x 3 units for the additional 45 minutes without any modifiers. Previously, the VA CCN was paying both services. Several months ago they started denying the 97811 stating its a "Medicare Unlikely Edit". At first they told me it was an internal processing issue and the claims would be reprocessed. Then I was told to do written appeals... now they keep sending them back "for internal review" and I have gotten no where. Have you encountered this problem? Is there a modifiers I should be using that I've missed? Im just curious if you have encountered the same issue. Thank you!

 

[Kocob]

Hi Kristy 2! This thread was back in May when I started having issue with VA claim process. I have figured out since then that VA (I am in legion 3) pays eval and RA visit for OV code as long as long as you follow the # of visit allowed within the auth. and yes, I use 25 modifier. As for 97811/97814. they have changed the allowed unit # from 3 to 2, so if you charge 2 units of 97811/97814, they will process without an issue. I found it way more work to fight for the payments and most likely not get paid at the end, so I just submit 97811/97814 x 2units. Off course, you need to notify the provider(s) so they can adjust on their end if needed.