RE: United Healthcare 97530 Denial, again!

[Guest guest]

Kathleen,

I must strongly disagree with your last statement of

" However, if the above is not the case, then you

should rethink how you are using the codes,i.e., use

one or the other if treating the same body part or

treatment is provided by one therapist " .

It is very possible to provide these two procedures on

the same day to a Medicare beneficiary, have this

treatment supported by documentation, append

modifier-59 to 97530, and be reimbursed for both. For

example, take a shoulder patient with 90 degrees of

shoulder flexion and abduction. A PT may provide

manual stretching and joint mobilization to increase

ROM and also have the patient perform skilled

functional activities that require the skills of a PT.

Documentation would support the time that both were

provided and the medical necessity of the treatment.

To do what you suggested could be considered upcoding

if the therapist " lumps " all treatment under one code

that reimburses the most. Even if they choose the

lesser paying code, it would still be a billing error

as they are not billing the appropriate CPT code that

best describes their treatment.

Providers should not worry about the use of

modifier-59 if their documentation supports the

skilled services and it meets the R & N criteria for

skilled therapy services.

Rick Gawenda, PT

Director PM & R

Detroit Receiving Hospital

www.gawendaseminars.com

--- " Oconnor, Kathleen " wrote:

> 97530 is a problem code for Medicare submissions

> also - throws out all sorts

> of other CPT's - due to NCCI edits - especially if

> billing for PT, OT and

> Speech on same date of service. Conversely, 97140

> will throw out 97530 if

> billed on same date of service - must attach the 59

> modifier to 97530 and

> must meet the guidelines specific to use of the 59

> modifier.

>

> If use of the two codes was specific to either two

> different specialties,

> i.e., PT and OT, providing 97140 and 97530 the same

> day, or if it involved

> 2 different body parts - then I'd say fight the

> fight. However, if the

> above is not the case, then you should rethink how

> you are using the codes,

> i.e., use one or the other if treating the same body

> part or treatment is

> provided by one therapist.

>

>

>

> United Healthcare 97530 Denial,

> again!

>

> Dear Group,

>

> Thank you for your previous replies on this topic.

> My inital

> question was - " We have been receiving denials from

> UHC for CPT

> 97530, this was once payable, does anyone have any

> insight " -

>

> Well, I resent the HCFA with at -59 modifer and one

> DOS was paid.

> Then I received a letter today stating they use CMS

> guidelines and

> the CPT manual published by the AMA. The exact line

> they sent me

> stated:

>

> 97140 97530 is an intregral part of CPT procedure

> code 97530. As a

> result, a separate charge for 97530 is not eligible

> for benefits

> under the plan.

>

> My question now is, if Medicare edits require a

> modifer and will pay,

> why is UHC giving us denials? Can this group advise

> me on how to

> appeal this? They are stating that " This

> reimbursement appeal is

> specific to us providing services that, while billed

> separately, are

> reimburseable by a comprehensive code. "

>

> I was not aware that 97140 is a comprehensive code

> that includes

> 97530. My understanding of the code is that they

> are unique

> services. Thank you in advance for your time and

> your efforts.

>

> Lori

> Holistic Physical Therapy LLC

> Monroe, MI

> Phone:

> Fax:

> Email: HPTLLC@...

>

>

>

>

>

>

>

>

>

>

>

> Looking to start and own 100% of your own Practice?

>

> Visit www.InHomeRehab.com.

> PTManager encourages participation in your

> professional association. Join

> and participate now!

>

> Please identify yourself in all postings to

> PTManager.

>