I work for the home care/pharmacy department of a medical facility. I was asked for coding for a patient who was having bilateral surgical procedures and was going to be receiving lovenox as a prophylaxis. This patient also has the dx of spastic diplegic CP. There is no history of any thrombosis of any kind in this patients history. I also did not see any documentation of any concerning blood work that would point to a concern for a possible blood clot. After going around with multiple nurses regarding this and stating there is no documentation supporting this, I finally responded that I was not going to jeopardize my certification that i worked hard to earn for this. They even went to the point of providing codes that they thought were relevant. I responded that none of the codes provided were supported in any documentation and this was my final response in this discussion. To me, this would be fraud and I do not want to be a part in this. Was I wrong to be upset by this?

We are an outpatient mental health facility. T1017 (Targeted Case Management) and H0038 (Peer Support) are not billable to Medicare, right? These codes have an E1 status:

"Both E1 and E2 are not paid by Medicare when submitted on outpatient claims (any outpatient bill type).

E1 is used for items and services that are:

-Not covered by any Medicare outpatient benefit category
-Statutorily excluded by Medicare
-Not reasonable and necessary"

I am asking because we have a client who has been conversing with Medicare customer service, and Medicare is telling the client that I need to submit claims to Medicare for these services. I did create a claim with a GY modifier just to see if it would go through (just for the purpose of receiving a denial) and the clearinghouse rejected the claim due to the HCPCS code. I called our MAC and the MAC said T1017 and H0038 are not even in their system so the claims will not go through. Even with this information, Medicare keeps telling the client that we need to submit these claims to Medicare. When I called the MAC to see why Medicare customer service would be telling the client this, the MAC just told me "I don’t know." I am about to pull my hair out. This is causing a lot of stress for the client and it is affecting the client’s mental health. I want to resolve this, as it has been going on for months.

So basically what I need to know is, is there any way to get the T1017 and H0038 claims through the clearinghouse to get a denial?

TIA!