URGENT CARE DENIALS

[Kathy O'Neal]

I'm a newly credentialed coder & have been given an opportunity to work our denials. For the most part I understand, but how do I 1) resolve issue's w/ Medicare LCD's, if the provider didn't put an acceptable code in his/her note? 2) are the 90 day global codes for fx's, dislocations only to be used if the provider intends to follow that patient for the whole global period? 3) Would a billing class be helpful in these area's?

 

[Alicia Scott]

Billing is not my best subject but I will jump in for a quick answer. We are getting some more experienced billers on-board soon.

My opinion:
First: Call them. Google it. You would be surprised what you find out. In addition feel free to ask on the forum.
Second: I am not sure I understand but you would not use the global code if the physician didn't provide the service. It must be the same physician or a partner (same group) to be included in the global period. Think of it this way. The global period is for the treatment that is normally expected during that time. If a different physician has to come in he is entitled to be paid. It most likely would be a consultation if it is another physician. If in doubt, again, call the payer to ask.
Third: Yes, and stay tuned, we are getting on here soon. In the mean time watch for those billing ladies to show up soon. I spoke with one just this week. I will text her today and see if she is registered for the forum.

Great questions. You are going to get to know your payers real well. Again, call them. Work on a relationship then share your info here. We need to know.

 

[Laureen]

1) resolve issue's w/ Medicare LCD's, if the provider didn't put an acceptable code in his/her note?

Seard the documentation for other diagnoses that did not get put on claim that support the procedure. You of course don't want to use a diagnosis just because it is on the list but often times there is a good diagnosis and only one gets put on the claim form. Put the new one and resubmit.

2) are the 90 day global codes for fx's, dislocations only to be used if the provider intends to follow that patient for the whole global period?

That is correct they should use a modifier is they they are only doing the intial treatment and don't plan on following up. Are you sure they are not going to be providing the follow up visits?

3) Would a billing class be helpful in these area's?

IMHO yes as dealing with deinals requires a deeper understanding of the reimbursement process than a coding education gives you. Our billing course will be launching in May if all goes as planned.

 

[Kathy O'Neal]

I work in an urgent care & whether or not a pt. has a fx, we don't follow the pts. for 90 days. Ex. A patient comes in w/ finger pain. Xray shows a fx. Most of the time the pt. is splinted & referred to an ortho specialist. Am I correct in billing an E/M -25, application of splint & supply? In the event a fx IS manipulated back into place, splinted & referred to an ortho specialist, how would I code this?

LCD's: I've gotten denials because a dx code that supports medical necessity isn't on the claim for Nebulizer treatments. The treatment is given to the patient, so should I go back to the provider & ask him/her to make an addendum to the provider's note w/ a dx code to support the neb tx?

I'm looking forward to more information regarding the billing course!!!

Thank you for your help.