I am looking for some help regarding Partnership Health Plan (CA Medicaid). We have received a request to refund the payment for several preventative encounters due to the wrong CPT Code being used. PHC is stating that the 99395 is to used for recipients ages 18-21. Their reasoning is they follow Medi-Cal’s guidelines. And per Medi-Cal’s guidelines :

Office visits for preventive medical care for children must be billed
using CPT-4 codes 99381 – 99385 and 99391 – 99395, as appropriate.
CPT-4 codes 99385 and 99395 are only to be used with recipients 18 – 21 years of age.
When these codes are billed inappropriately, reimbursement of claims is delayed for medical review and subsequently reduced to more appropriate rates.

Due to the above guideline they have completely left out all patient’s ages 22-39!!!

My billing department has written a letter providing the documentation showing the code description of CPT 99395 as well as explaining their error. They will not budge!

Can anyone provide any assistance? Should I provide an appropriate 99213-99215? Or let the billing department know we will need to refund PHC their money? :confused: