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I have a patient that is having bilateral ear tubes-to prevent any problems with hyperbaric oxygen therapy. The patient does not have any otorrhea, vertigo, subjective hearing loss, or tinnitus. No recent URI.
I was thinking of Z40.8 but I am not sure.
The patient has Medicare Jurisdiction L and there is not an LCD policy for CPT 69436 with modifier 50.
I would appreciate any help that you can provide.
Thanks,
Cammy Waterhouse, CPC
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The first denial came back stating:
"The 5 day assessment, ARD 8/3/17 pays for 8/1-8/3/17 and the 14 day/COT assessment ARD 8/10/2017 pays for 8/4-8/12-17. Billed RVB x 3 days and RUB x 9 days, validated RHB x 3days and RUB x 9days. The CMS RAI manual requires clinical documentation of daily therapy minutes provided. The ST minutes are incorrectly coded on the 5 day assessment compared to documentation received. Evaluation minutes are not to be included on the MDS."
On 8/1 this is what was done- 92507 (47 minutes) 92523 (55 minutes) and 96125 -59 (60 minutes). 8/2 92507 (36 minutes) and 8/3 92507 (31 minutes)
We had a total of 174 minutes of ST on the MDS. My interpretation of what they said was that they thought we were including the 55 minutes for the 92523 – Evaluation of Speech Sound Production. We did not, it was the 96125 with -59 Standardized Cognitive testing which includes face-to-face time administration and interpretation and report.
I sent that in over 2 months ago and we got yet another denial/upholding of the Level 1 stating:
This is what they state in a letter we received on 7/20/18.
Per CMS guidelines, CPT code 96125 is a billable code if face-to-face tested is completed and the interpretation is not completed by a technician or coputer. The treatment code completed for CPT code 96125 does not indicate how the testing and interpretation of testing were completed. Unable to determine if all time billed for CPT code 96125 was billable minutes. The eval is digitally signed by the ST, that’ show it reads and it’s our Speech Therapist. Are they reading that as Tech?!
In a letter we received 7/18 they state:
Per CMS guidelines, CPT code 96125 is a timed code and evaluation time cannot be billed on the MDS, only time for interpretation of the evaluation and preparation of the report are billable. Documentation provided does not distinguish between evaluation minutes and interpretation minutes.
So they have 2 letters stating 2 different reasons for denial. I’m not even the biller here, I’m the coder, I do diagnosis coding for my facility. And I’m the only one so it’s frustrating at this point. This is the first time I’ve worked in LTC/SNF so I need all the help I can get with this one.
Thank you for taking your time to read this!
Janet Beck, CPC
Thank you
MS
thanks
I am billing 97110, 97530, and 97535 with a GO modifier. The adjusted reimbursement is about 25% less than the agreed rate.
Is there anyway to get full payment? Should I be using modifier 59?
I am hoping that someone can help me with the above billing are their cpt codes for these services and are license required to bill this type of service, my provider is license by DCF to do PHP , Out patient Detox , Intensive Outpatient, they want to offer this service as well, any help would be great.
Thanks
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