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1

March 01, 2014

Billing

Code

DOS

Issue

Law

Payments

Award

IBR

#

DRG 460

1-18-to 01-23-2013

Implants not separately reimbursed for DRG 460

For discharges occurring on or after January 01, 2013 but before January 01, 2014 an additional allowance shall be made for spinal deceives

MS-DRGs 453, 454, 456, 028, 029 and 030 0 For insurance 100

64635

February 11, 2013

Denial of the two units of 64636 appropriate

The report submitted identified four facet joint sites; bilateral L3-L4 and bilateral L4-L5. Based on the AMA CPT coding guidelines and documentation submitted no additional reimbursement

Prior payments $2,525.29 seeking additional $703.70

No additional

payments 101

64636

February 11, 2013

Denial of the two units of 64636 appropriate

The report submitted identified four facet joint sites; bilateral L3-L4 and bilateral L4-L5. Based on the AMA CPT coding guidelines and documentation submitted no additional reimbursement

Prior payments $2,525.29 seeking additional $703.70

No additional

payments 101

93307

February 12, 2013

Denial of reimbursement as 93320 and 93325 included in 90037

Per Review of the centers for Medicare Medicaid services (CMS) National Correct Coding Initiate (NCCI) edits CPT 93307is considered the

comprehensive code and CPT 93320 and 93325 are considered components of 93307. The CMS NCCI active edits indicate when CPT 93307, 93320 and 93325 are submitted for the same beneficiary on the same date of service CPT 93307 is eligible for payment and CPT 93320 and CPT 93325 are

denied. No payment

No additional

payments 104

93320

February 12, 2013

Denial of reimbursement as 93320 and 93325 included in 90037

Per Review of the centers for Medicare Medicaid services (CMS) National Correct Coding Initiate (NCCI) edits CPT 93307is considered the

comprehensive code and CPT 93320 and 93325 are considered components of 93307. The CMS NCCI active edits indicate when CPT 93307, 93320 and 93325 are submitted for the same beneficiary on the same date of service CPT 93307 is eligible for payment and CPT 93320 and CPT 93325 are denied. Per Review of the centers for Medicare Medicaid services (CMS) National Correct Coding Initiate (NCCI) edits CPT 93307is considered the

comprehensive code and CPT 93320 and 93325 are No payment

No additional

(2)

2

March 01, 2014

considered components of 93307. The CMS NCCI active edits indicate when CPT 93307, 93320 and 93325 are submitted for the same beneficiary on the same date of service CPT 93307 is eligible for payment and CPT 93320 and CPT 93325 are denied.

93325

February 12, 2013

Denial of reimbursement as 93320 and 93325 included in 90037

Per Review of the centers for Medicare Medicaid services (CMS) National Correct Coding Initiate (NCCI) edits CPT 93307is considered the

comprehensive code and CPT 93320 and 93325 are considered components of 93307. The CMS NCCI active edits indicate when CPT 93307, 93320 and 93325 are submitted for the same beneficiary on the same date of service CPT 93307 is eligible for payment and CPT 93320 and CPT 93325 are

denied. No payment

No additional

payments 104

93307 June 21, 2013

Denial of reimbursement as 93320 and 93325 included in 90037

Per Review of the centers for Medicare Medicaid services (CMS) National Correct Coding Initiate (NCCI) edits CPT 93307is considered the

comprehensive code and CPT 93320 and 93325 are considered components of 93307. The CMS NCCI active edits indicate when CPT 93307, 93320 and 93325 are submitted for the same beneficiary on the same date of service CPT 93307 is eligible for payment and CPT 93320 and CPT 93325 are

denied. No payment

No additional

payments 108

93320 June 21, 2013

Denial of reimbursement as 93320 and 93325 included in 90037

Per Review of the centers for Medicare Medicaid services (CMS) National Correct Coding Initiate (NCCI) edits CPT 93307is considered the

comprehensive code and CPT 93320 and 93325 are considered components of 93307. The CMS NCCI active edits indicate when CPT 93307, 93320 and 93325 are submitted for the same beneficiary on the same date of service CPT 93307 is eligible for payment and CPT 93320 and CPT 93325 are denied. Per Review of the centers for Medicare

Medicaid services (CMS) National Correct Coding No payment

No additional

(3)

3

March 01, 2014

Initiate (NCCI) edits CPT 93307is considered the comprehensive code and CPT 93320 and 93325 are considered components of 93307. The CMS NCCI active edits indicate when CPT 93307, 93320 and 93325 are submitted for the same beneficiary on the same date of service CPT 93307 is eligible for payment and CPT 93320 and CPT 93325 are denied.

93325 June 21, 2013

Denial of reimbursement as 93320 and 93325 included in 90037

Per Review of the centers for Medicare Medicaid services (CMS) National Correct Coding Initiate (NCCI) edits CPT 93307is considered the

comprehensive code and CPT 93320 and 93325 are considered components of 93307. The CMS NCCI active edits indicate when CPT 93307, 93320 and 93325 are submitted for the same beneficiary on the same date of service CPT 93307 is eligible for payment and CPT 93320 and CPT 93325 are

denied. No payment

No additional

payments 108

99214

February 05, 2013

Down coded from 99214 to 99213 no additional reimbursement

Based on a review of the documents the provider did not meet the requirements of CPT 99214: CPT 99214 Office or other outpatient visit for the Evaluation and Management of an established patient which requires at least 2 of these three key components:

1. Detail history

2. Detail examination

3. Medical decision making of moderate

complexity 99213 = $52.38

No additional

payments 111

99212

January 31. 2013

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination:

The Provider billed for CPT Evaluation and Management code 99212 and Prolonged Services code 99358. Per the OMFS General Information and Instructions, where the physician is required to spend 15 minutes before and / or after direct (face-to-face) patient contact in reviewing extensive records, tests or in communication with other professionals, the CPT code 99358 may be charged in addition to the basic charge for the appropriate

Based on the documentation submitted an additional allowance of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not

warranted. The

The additional reimbursement of $66.86 for CPT 99358 is warranted based on the following: PPO

(4)

4

March 01, 2014

Straightforward medical decision making.

Evaluation and Management code. The report for date of service 1/31,2013 submitted by the Provider, indicated the provider spent thirty minutes on record review. The total time spent on record review was documented on the last page of the report. 99358 is warranted

requirements of CPT 99358 by the claims administrator was inappropriate

reimbursement CPT 99358 (each 15 minutes) =$33.43 Total time billed 30 minutes = 2 units $33.43 x 2 (units) = $66.86

99358

January 31. 2013

Prolonged evaluation and management services before and / or after direct patient care.

The Provider billed for CPT Evaluation and Management code 99212 and Prolonged Services code 99358. Per the OMFS General Information and Instructions, where the physician is required to spend 15 minutes before and / or after direct (face-to-face) patient contact in reviewing extensive records, tests or in communication with other professionals, the CPT code 99358 may be charged in addition to the basic charge for the appropriate Evaluation and Management code. The report for date of service 1/31,2013 submitted by the Provider, indicated the provider spent thirty minutes on record review. The total time spent on record review was documented on the last page of the report. 99358 is warranted

Based on the documentation submitted an additional allowance of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not

warranted. The requirements of CPT 99358 by the claims administrator was inappropriate

The additional reimbursement of $66.86 for CPT 99358 is warranted based on the following: PPO Allowance reimbursement CPT 99358 (each 15 minutes) =$33.43 Total time billed 30 minutes = 2 units $33.43 x 2 (units) =

$66.86 117

99086 January 31. 2013

Reproduction of chart notes

The second disputed code is CPT 99806 “Charts Notes.” Based on the OMFS General Information and instructions, request for chart notes shall be in writing and be made only by the Claims

Based on the documentation submitted an additional allowance

No additional

(5)

5

March 01, 2014

Administrator. A request for chart notes from the claims administrator was not submitted as part of the documentation. Reimbursement for CPT 99086 is not warranted.

of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not

warranted. The requirements of CPT 99358 by the claims administrator was inappropriate

99085

January 31. 2013

Special external photography for documentation of significant medical progress or condition may warrant an additional charge

The third dispute code is charges for photos billed as CPT 99085. Per the OMFS the procedure code 99085 is listed as a “By Report “ service.

Procedures without unit values or “By Report” are defined as “unlisted service or one that is rarely provided, unusual or variable may require a report demonstrating the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time effort and equipment necessary to provide the service.” The documentation to support the “By Report” separate reimbursement was not submitted. Services such as “photos” are considered

procedures that are commonly carried out as an integral part of a total service, and does not warrant separate reimbursement. The denial of procedure code 99085 by the claims administrator was appropriate.

Based on the documentation submitted an additional allowance of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not

warranted. The requirements of CPT 99358 by the claims administrator was inappropriate

No additional

payments 117

99080

January 31. 2013

Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form

The fourth dispute billed code is CPT 99080. The Provider submitted a report titled Comprehensive Dermatologic Re-evaluation Report and Request for Authorization for follow-up visits and treatment. The provider is the Primary Treating Physician. The contents of the report are consistent with the description and requirements of a Primary Treating Progress Report (PR-2). Per review of the OMFS General Information and Instructions under the

Based on the documentation submitted an additional allowance of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not

warranted. The

No additional

(6)

6

March 01, 2014

Reports section CPT 99081 is used when billing for Primary Treating Physician’s Progress Reports. The code assignment and reimbursement pf CPT 99081 by the claims administrator was appropriate

requirements of CPT 99358 by the claims administrator was inappropriate 97799 Modifier 86 February 25, 2013 through march 01, 2013 Functional restoration program

CPT 97799 Unlisted physical medicine service or procedure Modifier 86 is to be used when prior authorization was received for services that exceed the OMFS ground rules

Based on a review of the PPO contract, the reimbursement rate for services rendered would be 90% of the current applicable fee schedule. The Official Medical Fee Schedule does not list a value for CPT 97799. The provider submitted copies of other explanation of reviews demonstrating their usual and customary charge of $6,000.00 for 5 days of functional restoration program services. The reimbursement should have been on 90% of the billed charges of the providers usual and customary charge of $6,000.00

Additional reimbursement of $3,001.45 is warranted for the Official Medical Fee Schedule code 97799.

Additional amount awarded to the already paid $2,398.55 is

$3,001.45 126

97690 Down coded February 25, 2013 through march 01, 2013

Down coded from 9779 86

CPT 97799 Unlisted physical medicine service or procedure Modifier 86 is to be used when prior authorization was received for services that exceed the OMFS ground rules

Based on a review of the PPO contract, the reimbursement rate for services rendered would be 90% of the current applicable fee schedule. The Official Medical Fee Schedule does not list a value for CPT 97799. The provider submitted copies of other explanation of reviews demonstrating their usual and customary charge of $6,000.00 for 5 days of functional restoration program services. The reimbursement should have been on 90% of the billed charges of the providers usual and customary charge of $6,000.00

Additional reimbursement of $3,001.45 is warranted for the Official Medical Fee Schedule code 97799.

Additional amount awarded to the already paid $2,398.55 is

$3,001.45 126

97691 Down coded February 25, 2013 through march 01, 2013

Down coded from 9779 86

CPT 97799 Unlisted physical medicine service or procedure Modifier 86 is to be used when prior authorization was received for services that exceed the OMFS ground rules

Based on a review of the PPO contract, the reimbursement rate for services rendered would be 90% of the current applicable fee schedule. The Official Medical Fee Schedule does not list a value for CPT 97799. The provider submitted copies of other explanation of reviews demonstrating their usual and customary charge of $6,000.00 for 5 days of functional restoration program services. The reimbursement should have been on 90% of the billed charges of the providers usual and customary charge of $6,000.00

Additional reimbursement of $3,001.45 is warranted for the Official Medical Fee Schedule code 97799.

Additional amount awarded to the already paid $2,398.55 is

(7)

7

March 01, 2014

99244

February 08, 2013

Office consultation for a new or established patient, which requires these 3 key components. A

comprehensive history; A comprehensive

examination; and Medical decision making of moderate complexity

Per the OMFS Information and Instructions, the referral for the transfer of the total care or specific care of a patient from one physician to another does not constitute a consultation. The reimbursement of 99244 is not warranted. Based on the review of the medical record criteria of CPT 99213 was met.

The documentation submitted warranted reimbursement of the Evaluation and Management services. The denial of the report code 99080 by the Claims Administrator was appropriate/ The criteria of 99213 was met based on the review of the medical record for date of service 2/8/2013

Ordered

$56.93 / 99213 130

99213

February 08, 2013

Office or other outpatient visit for the evaluation and management of an established patient which requires at least 2 of these 3 key components.: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity.

Expanded problem focused history is defined as meeting the requirements of or documenting the chief complaint, a brief history of present illness and problem pertinent system review. The patient’s chief complaint was documented, duration of complaint associated signs and symptoms of illness were discussed as well as a review of the body system directly related to the chief complaint. The provider prescribed medications and reviewed the Primary Physician’s Initial report. The medical decision appears to be low complexity.

The documentation submitted warranted reimbursement of the Evaluation and Management services. The denial of the report code 99080 by the Claims Administrator was appropriate/ The criteria of 99213 was met based on the review of the medical record for date of service 2/8/2013

Ordered

$56.93 130

99080

February 08, 2013

Special reports such as insurance forms, more than the information conveyed in the usual medical communications

The provider submitted a report titled Report of Psychiatric Consultation. The report submitted was addressed to the Primary Treating Physician. The Provider prescribed medication and requested a follow-up visit, therefore, is considered a Secondary

Per the OMFS information and Instruction Guidelines, reports

submitted by the 0

(8)

8

March 01, 2014

or standard reporting form Treating Physician to the worker. Per the OMFS information and Instruction Guidelines, reports submitted by the Secondary Physician to the Primary Treating Physician are not Reimbursable

Secondary Physician to the Primary Treating Physician are not

Reimbursable

99358

January 06, 2013

Prolonged evaluation and management service before and / or after direct (face-to-face) patient care (e.g. review of extensive records , job analysis, evaluation of ergonomic status work limitation, work capacity or

communication with other professional and / or the patient / family); each 15 minutes

CPT code 99358 may be charged in addition to basic charge for the appropriate Evaluation and Management Code. OMFS Evaluation and Management code description indicates the code 99358 is used when the physician provides prolonged services not involving direct (face-to-face) care that is beyond the usual services in either the inpatient or outpatient setting. The code 99358 is to be reported in addition to other physician service, including evaluation and management services at any level and report charge (99080)

Based on a review of the final explanation of review, it appears the Claims Administrator reimbursed the Provider for four units of CPT code 99358. The provider billed the code 99358 (13 units) and report charge 99080. The provider

documented at the beginning the report, three hours and 15 minutes of time spent on record review, the Provider’s own file and report

preparation. The provider documented and billed for thirteen units of CPT 99358. The partial payment of CPT 99358 was inappropriate

FS Allowance $425.18 Provider billed 195 minutes = 13 units $425.18-$130.82 (previously

paid) = 294.36 166

(9)

9

March 01, 2014

2013 insurance forms, more

than the information conveyed in the usual medical communications or standard reporting form.

basic charge for the appropriate Evaluation and Management Code. OMFS Evaluation and Management code description indicates the code 99358 is used when the physician provides prolonged services not involving direct (face-to-face) care that is beyond the usual services in either the inpatient or outpatient setting. The code 99358 is to be reported in addition to other physician service, including evaluation and management services at any level and report charge (99080)

of the final explanation of review, it appears the Claims Administrator reimbursed the Provider for four units of CPT code 99358. The provider billed the code 99358 (13 units) and report charge 99080. The provider

documented at the beginning the report, three hours and 15 minutes of time spent on record review, the Provider’s own file and report

preparation. The provider documented and billed for thirteen units of CPT 99358. The partial payment of CPT 99358 was inappropriate

99080

January 25, 2013

CPT 99080 Special reports such insurance forms, more than the information conveyed in the usual medical communications or standard reporting form

The provider submitted a “Primary Treating Physician Supplemental Report Review of Medical Records” report. The report documented a review of an e-ray and provider comments. The type of report submitted by the provider was not a Primary Treating Physician Progress Report (PR-2), or separately reimbursable report as described in the

There is no additional reimbursement warranted per the Official Medical Fee Schedule code

(10)

10

March 01, 2014

OMFS General Information and Instructions Separately Reimbursable Treatment Reports section, therefore the denial of the report code 99080 was correct

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