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Tuesday, June 7, 2011

CPT 93010, 71010, 71020 - Avoiding X-ray or EKG - Duplicate denial

Chest X-ray or EKG: Duplicate Denials – M80, CO15


Denial Reason, Reason/Remark Code(s)

  • M-80, CO-18 - Duplicate Service(s): Same service submitted for the same patient, same date of service by same doctor will be denied as a duplicate

  • CPT codes: 93010, 71010, 71020
71010 Radiologic examination, chest; single view, frontal

71015 stereo, frontal

71020 Radiologic examination, chest; 2 views, frontal and lateral;

Resolution/Resources


First: Verify the status of your claim before resubmitting. You can determine the status of a claim through the Online Provider Services (OPS) tool or by calling the Interactive Voice Response unit (IVR).



Online Claim Status Verification through OPS


  • All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.

  • Access the introductory article to learn more: Click on the 'Introducing Online Provider Services' graphic on the top of any of our main contract Web pages

  • One important consideration: Only one Provider Administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The Provider Administrator can then grant permission to additional users related to that PTAN/NPI.

  • Billing services and clearinghouses should contact their provider clients to gain access to the system

  • Specific instructions for accessing claim status information through OPS are available in the OPS User Manual.

  • Submit multiple 'identical' services on the same claim. Use the quantity field to reflect the number of services. If the services cannot be submitted on a single claim, use CPT modifier 76 and specify the exact times of each service.

  • On electronic claims use the documentation record to specify the exact times that each diagnostic service (e.g., chest x-ray, EKG, etc.) was done

  • On electronic claims use the documentation record to explain why more than one diagnostic service was done on the same date by the same provider

  • Attachments (e.g., signed radiology reports, signed EKG reports, etc.) for paper claims must identify the patient’s name, Health Insurance Claim number, date of service and other pertinent information (e.g., times):

  • Attachments must be a full page (8 ½ x 11)

  • On appeal signed medical records (e.g., radiology reports, EKG reports, etc.) may be sent as evidence to show why more than one diagnostic service was billed on the same date by same or similar providers from the same group

  • If you need to make a correction to a claim that was incorrectly denied as a duplicate, you may request a Telephone Reopening

  • Access specific instructions for documenting and submitting CPT modifier 76 through the Modifier Lookup
Guidelines from BCBS

Chemotherapy - Evaluation and Management services will generally be denied when submitted on the same date of service as a chemotherapy administration code. If a significant, separately identifiable service is performed, modifier 25 is used. Office notes must document the significant, separately identifiable service. 

Intravenous infusion codes are not allowed in addition to intravenous chemotherapy administration services unless the intravenous infusion represents a treatment apart from chemotherapy administration. The reason for a separate intravenous infusion should be noted in the medical record, and the service code modifier for a distinct procedure appended to the procedure code for intravenous infusion.

Clinical photography - for documentation/record-keeping purposes is considered to be an integral part of an evaluation and management (E&M) service or procedure and not eligible for separate reimbursement consideration.

Chronic Care Management Services – codes 99490 and G0506 are considered incidental to other evaluation and management services and not eligible for separate reimbursement. Critical Care Services - Codes 36000, 36410, 36415, 36591, 36600, 43752, 43753, 71010, 71015, 71020, 92953, 93561, 93562, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762, and 99090 are considered incidental to 99291 and 99292(Critical Care Services). 

Critical care service procedures will be denied as incidental when submitted with Neonatal and Pediatric Critical Care services (99466, 99467, 99468, 99469, 99471,  99472, 99475, 99476). The critical care service procedures are included in the pediatric and neonatal critical care codes. Separate reimbursement is not allowed for  incidental services. 

Supplies are not covered when they do not require a prescription and can be purchased by the member over-the-counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during the course of an office visit are generally considered incidental to the office visit. Compression/pressure garments, elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered.

Transvaginal Ultrasound - Transvaginal ultrasound (76830) is considered mutually exclusive to a hysterosonography with or without color flow Doppler (76831). Venipuncture - Refer to policy “Code Bundling Rules Not Addressed in Claim Check.”

Vision Services - Determination of refractive state (92015) performed incidental to a medical eye exam is permissible and may be covered when performed outside of any global allowance and subject to member benefits.

X-Rays - When single view and double view chest X-Rays are billed together (71010 and 71020), only the double view X-Ray is allowed. When the entire spine, survey study is billed (72082) with cervical spine films (72040), thoracic spine films (72070) or lumbosacral spine films (72100) only the entire spine, survey study code is allowed. When a single view X-Ray code is billed with a multiple view XRay code, only the multiple view X-Ray code is allowed (e.g., 72020 with 72040, 72070, or 72100). Only one professional and one technical component are allowable per X-Ray.

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