PROVIDER INELIGIBLE TO FILE CPT 81001 - Denial reason

DESCRIPTION OF THE ISSUE

We received denials for the CPT 81001 as “Provider is not certified eligible to perform this procedure” - CPT 81001 (Urinalysis with microscope) 

CONCEPT

Any provider should be aware of his eligibility of the services to be performed for appropriate reimbursements. 

SOLUTION

Per Coding Dept’s advice we changed CPT from 81001 to 81002 (Urinalysis without microscopy) and refiled all the denied claims for reprocessing.  The refiled claims were paid successfully. 

REJECTION OF WHOLE CLAIMS WITH J CODES FOR NDC# UPDATE cpt code - j7613, j7609

DESCRIPTION OF THE ISSUE

Claims filed without or incorrect NDC#s, MCD HMO carriers (Staywell/Health Ease) rejected entire claim for NDC# updates, instead of processing denial only for J Codes.

CONCEPT

All injection drug codes should be billed along with NDC# updates for the claims to be reimbursed.

SOLUTION

Carriers’ database setup has been modified to reject the entire claim when filed with J Code without/Incorrect NDC#s, instead of processing denial only for the J Code.  So we segregated J code as a separate claim.  This enhanced payment for rest of the CPTs and the J code alone was denied for need of NDC#.

IS cpt code 81001 valid - replacement code G0431

CPT G0431 replaces CPT 80101 for Drug Screen Testing 

 

Change Request 6852 addresses CPT G0431 "Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class" as a direct replacement of CPT 80101.  

The following conditions become effective on April 1, 2010: 

Providers must use CPT G0431 when billing for these services CPT 80101 will no longer be covered by Medicare for dates of service January 1, 2010 and after

For complete information, refer to the CMS Medicare Leaning Network (MLN) article MM6852 "Clinical Laboratory Fee Schedule (CLFS) - Special Instructions for Specific Test Codes (CPT Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW, and G0431QW)."