Coding & Billing Q&A
I billed a PIP case G0283 for electric stimulation along with a CMT, manual therapy, and
therapeutic exercises, but had the electric stimulation denied for being “bundled.” Is this a
correct denial?
Not that I can see, and I looked to give them the benefit of the doubt since the PIP rules have
changed so recently. If you are not aware of the new PIP rules, fee schedules and daily maximum
codes, you should refer to New Jersey’s Department of Banking and Insurance website.
Now back to the specific issue in your question, for which I did find something very interesting in
our favor for a change. First the bundling claim: PIP follows the same basic bundling rules as
CMS defines in the CCI edits and as used by other carriers with few pre-assigned exceptions.
These bundling rules are defined by tables, in this case referred to as the “Column 1 and Column
2 table.”
Nowhere in this table does it indicate G0283 is a bundled procedure to any other therapy or
modality under any circumstance. Pretty cut and dry. If you get this denial, simply appeal it by
telling them to correct the denial or show you what documentation they used to determine it.
Now for the exciting find. Electric stimulation from a CPT coding perspective has traditionally
been split into attended (97032) and unattended (97014). But starting with Medicare (and then the
private carriers jumped onboard to save a buck) payers began to lump them together under the
CMS created HCPCS code G0283 for electric stimulation for non-wound care.
This gave CMS and other payers a way to control some of the costs and reimbursement issues
surrounding electric stimulation. The payers began requiring electric stimulation be submitted as
G0283 regardless of whether it was attended or unattended and resulted in savings for them.
However, it appears that the PIP fee schedule missed the boat on the designation.
Electric stimulation unattended (formerly CPT code 97014) is payable at $0.00, and G0283 is
payable at $16.47 north and south. Here’s the bonus: Electric stimulation attended (by a licensed
provider acting within their scope) is still billable as CPT code 97032 and is payable at $22.15
(south) and $23.15 (north)! So PIP is not following the pay reduction efforts by combining the 2
codes, but instead appears to have merely replaced 97014 only with G0283.
So if electric stimulation is delivered as attended, don’t sell yourself short with G0283 for PIP
patients, and bill the appropriate 97032 to receive a significantly higher, appropriate payment.
I received a fax from MultiPlan regarding a claim I submitted to UnitedHealthcare asking
me to accept an expedited reduced payment. What do I do about this?
UnitedHealthcare obviously received the claim and is responsible to process it in a timely fashion
anyway, so what benefit would there be in expediting payment and accepting even further
reduction from an already abusive pay scale? IGNORE IT.
Can you imagine UnitedHealthcare going to its claims adjustors at the end of each day and saying
“We know you earned your salary for today, which by the way is already reduced annually, but
how about we pay you 65% of what you earned today instead of you waiting for what we really
owe you in your paycheck next week?” Better yet, how about a plan sponsor telling
UnitedHealthcare that although their premium isn’t due for another couple of days, they are going
to pay just 65% of what they really owe UnitedHealthcare but it should be considered to be
expedited.
UnitedHealthcare wouldn’t stand for it and neither should you. Wait for the maximum payment
you are due and don’t fall for any promises of expedition. You have no obligation to accept it or
even respond.
I was asked to write a special report for another doctor, a surgeon, who is applying to
precert a breast reduction surgery for a patient I have been treating for neck and back
pain. I wrote the report; is this something I can get paid for and if so how do I bill it?
There is a CPT code for your report/letter and it is 99080. This is precisely the kind of situation
that CPT code is intended to represent: so a provider can be reimbursed for preparing a special
report or communication other than what is commonly communicated between caring providers.
John Kelly serves as the in-house insurance consultant to ANJC and is a former Senior Investigator for
Aetna insurance. He currently assists providers in education, billing and coding compliance, mock audits,
and post-payment audit disputes or defense through Kelly Coding & Compliance. For more info email
johnkelly@kellycodingandcompliance.com.