Re: OT procedure code--Yes--it matters

[Guest guest]

Betty--brace yourself--it is NOT the procedure code per say-or that too but --it

is the way it is being billed------a chunck of one hour of just one

code----which is NOT allowable by  insurance. Our OT breaks down the procedurees

and has different codes so that each 15 min segment gets a different

code--another OT we had told us they were not qualified to do the other codes so

they only broke it up into two codes--allocating 2  15 min units to each--and

that got fully reimbursed as well--I mean at 60% until our maximum out of

network out of pocket was met and then it was covered at 100% as is our

speech--with a regualr progress report and doctor's letter of medical

necesity---which has to sound good---like they really believe in it and they can

cut and paste the ASHA neurological damage definition of apraxia as well as

recommended treatment. For OT--much of the same--except usually OT is covered

more--speech notoriously isn't--and parents do not know

how to get around it--but I've been doing this for 4 years now-now with very

god insurance--that covers speech--but my first plan had no speech coverage and

I still got it covered--again--by knowing how to make the argument and finding

doctors who can write a good leter of medicla necessity--as they all should.

And don't beat yourself about no OT in network-----there are not OTs in

network--- which in fact mreans they should be  reimbursing you back as if they

were--if your child needs OT--and you have a letter saying o--describing the

diagnoses of low tone-ICD-9 code 781.3.  So i there are no OTs in network--thsi

si their problem--not yours. That's another insurance trick i learned--if a

needed provider isn't in network withing a certain radius----they are obligated

by law to accept that out of netowork provider as if they were in network. For

example our daughter needed PROMPT and there are no in-network PROMPT trained

therapists not withing the established radius--not even 100 miles away-----so

well----they should have reimbursed fully with a doctor's letter saying that's

what was needed----but I never went after that one since with 5 speech sessions

and 1 OT sessions per week--we reach our maximum out of pocket  out of network

pretty early on--and the

rest is free ride--not heacache free--but with appeals/and now claims sent

directly to one designated Aetna processor--so it doesn't look like wild monkeys

processed the claims any more--it's all been working out.  Occasionally things

get out of line again and I contact the HR person who puts me in touch with the

Aena Laieson person and we get it back on track again. i told them that the over

30 claims a month processed so haphazardly were not only giving me an ulcers but

ensuring that I woudl soon start needing mental health services--i couldn't

sleep at night with all the mistakes they were making paying double for soem

segments and not at all for others----the OT in particular was out of control

and that was when I called the HR person in tears and said this was abuse--she

understood and gave me the right contact--who also understood. it's been pretty

easy sailing since.

So here is the tip:--break down the hour into different segments with different

procedural codes--I think 2 15 min units per code is max they allow----but try

to get 4 just to be sure--unless  your provider isn't licensed for all 4 as one

of mine wasn't at soem point.

Anyway, here they are:

Kinetc activities--15 min 97530

Therapeutic exercises --15 min 97110-59

Neuromuscular reeducation-15 minutes 97112-59

Self Care/home management training - 97535-59

Together all these add up to 1 h--in our area billed at $150--so 437.50 per 15

min segment.  We've not had any problems since. resubmit all paast claims with

the appropriate codes.  if your provider objects and says theya r enot licensed

for any of them--just have them do the ones they are licensed for----we had the

same resulkts with 2 15 min units for the first 2 codes--but eventually gave up

that provider--and yes--their coding was part of the problem--their billd were

incredibly difficult to read --and their reports were most unuseful and

unprofessional--so we stuck with the provider that not only works the best with

my child--but also puts in the effort to help parents get reimbursed. otherwise

had I stuck with just that first provider--i woudl ahve never known and never

gotten more than $60 paid out of the $150  pay for each session. live and

learn--and ask other parents

All the best,

Elena

From: wbetty2006 <wbetty2006@...>

Subject: [ ] OT procedure code

Date: Monday, October 11, 2010, 2:12 PM

Hi,

My child has hypotonia and apraxia. we have an OT who is considered as out of

network provider by our insurance company. our OT gave us the procedure code of

97530 in the invoice and the price is $100 per hour. but the allowance of this

service in our insurance company is only $50 according to the procedure code. I

do appreciate that anyone could share some information of your OT code and what

is the allowance for your OT procedure code in your insurance?

Betty

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