Medicare denial

Hi,
Hoping that somebody can help me with these coding.
Patient is here for right knee pain. Assessment made by physician was:
401.1
715.16
692.9

And the procedure done to patient: kenalog injection.

CPT® used: 99214-->401.1 and 692.9
20610--> 715.16
J3301-- > 715.16

But MC(medicare denied it: - What should be the right code used?

Thanks

re: Medicare denial

Why did they deny and did you use a modifier -25?

re: Medicare denial

For E/M code 99214?

re: Medicare denial

Did you put modifier -25 on E/M code?

re: Medicare denial

99214-25
J3301-59
96372

What what the denial reason?

re: Medicare denial

ACK/REJECT RELATIONAL - Detailed description of service.

re: Medicare denial

Ah....that has to do with your description of the J3301. Is that a Gateway EDI rejection or a Medicare rejection? It sounds like the Gateway rejection. How to fix that depends on your software, but they are wanting to see the full decription of the J3301 on the claim before they will forward the claim.

re: Medicare denial

The payer denied it..

re: Medicare denial

I'd still look into the description of the drug. I bill this injection almost daily and this has been an issue with this particular drug. Good luck.

re: Medicare denial

You mean they don't accept it?

re: Medicare denial

They've just gotten very particular about this drug in that you have to make sure the description of the drug needs to be on the claim. For the kind my doctor uses, I put "Triamcinolone Acetonide 40mg/ml NCD #00003029328" in the remarks field and you have to make sure the unit measure is correct. I believe for this drug you have to use 'ml'. But, it IS covered by Medicare. Again, make sure you have a '59' modifier on the drug code and a '25' on the office visit.

re: Medicare denial

Sherry, you mentioned utilizing modifier 59 on the drug code. Why must this be done? Just wondering as I would never have thought of utilizing that modifier of last resort. I'm very interested in your rationale for doing so. Thanks for your help. ---Suzanne

re: Medicare denial

Hi,
How about if this is the procedure done.

Kenalog injection:
knee 40 mg of kenalog was injected with into left knee after 5 ml of 1% lidocaine and 5ml of 0.5% marcaine was injected first. Skin was sterilized first using betadine then wiping with alcohol. Ethyl chloride was topically sprayed immediately prior to needle penetration . Patient tolerated it well without complications..

THanks

re: Medicare denial

20610-LT
J3301 x 4

re: Medicare denial

Sherry,
I know your response is a couple weeks old, but wanted to follow up as to why would you append modifier 59 to the drug code? Would it be processed thru and paid if you didn't add? I'm finding it odd that a modifier 59 would be attached to a drug code, but this isn't the first time I've heard about it being done and am interessted to find out if this is a common practice. Enjoyed your responses to the original poster of this question. ---Suzanne

re: Medicare denial

Your clearing house might have to provide a brief description of that injection while transmitting it to medicare in the block 19 as J3301 is an un specified code on exclusive conditions..
Also check that if you have billed with an appropriate NDC drug code..... Let me know if you need a list of those NDC's....

re: Medicare denial

Also you should not use modifier 59 on J3301 as its not accepted by Medicare, if you have used it please re-file with valid NDC's and without a modifier 59 on it,..... You can also call your clearing house to have a description added in block 19 to avoid future denials

re: Medicare denial

By chance, is this patient within a global period?