I say the total opposite--fight for the work that you do. We get paid for ADD codes in Michigan. We had to fight the carriers, but we get paid. We generally bill them with a 90862, but do get paid with 99212-99215. Brenda Roderick Office Manager Kids Creek Children's Clinic ----- Original Message ----- From: "Kevin Perryman" <> To: "'Ajey Godbole'" <>; <> Sent: Wednesday, August 04, 2004 10:54 AM Subject: RE: BCBS not paying for ADHD > First, Don't waste your time fighting this issue. As far as your > billing manager goes they are right on the mark. This is one of the > battles that you should just walk away from. Look for the battles that > you at least have some chance of winning. Because the plan defines > these codes as Mental Health Codes they have State and/or Federal law on > their side. Specifically if it is an individual policy they have the > Texas Department of Insurance Rules and Regulations on their side for > benefit coverages provided. If the plan is an employer plan then it > falls under ERISA as a Benefit Plan issue. > > Second, recognize this fact and develop office policies to handle the > issue in the future. > > Many insurance carriers will not pay for ADD/ADHD work ups performed by > pediatricians. However they will pay when performed by a Neurologist or > psychologist or psychiatrist. Inform the families up front that many > insurance carriers consider this to fall under mental health benefits > and that if you perform the evaluation the family may have to pay the > full charge. Also, let them know that if they chose to they can have > the evaluation performed by a neurologist or a psychiatrist, they may > not be liable for the services as insurance may cover it under their > benefits. At that point it is the patients choice on what to do. > > The best thing to do is to know that codes in the 290-319 series are > Mental Health Codes and that they are not reimbursed to PCP's. Know > that when patients call to schedule evaluations for School Problems, > Behavior problems, Antisocial behaviors, etc. that they need to be > informed that as a PCP you can see them for those problems, however, > most insurance companies do not reimburse such services in the PCP > office and that they may be better off seeking care from a Neuro or > Psych. Tell them they need to call their plan and verify coverage and > that after doing so they can call back if they want to be seen by you. > When they come be sure to have them sign a waiver stating everything you > told them and that they may be responsible based on their insurance > plans determination of benefits. If denied as a non-covered service by > a PCP they will be responsible for the charges. > > Finally, after the initial diagnosis is made, you are no longer seeing > the patient for 314.00 or 314.01 but for V58.69 Management of Long-term > High Risk Medications. Typically you are seeing the patient for > medication adjustments Adderall, Strattera, etc. Bill a level 99213 or > 99214, some cases 99215. > > ************************************************************************ > ************** > Billing 99212, 99213, 99214 with V58.69 > > We are paid 100% of the time from BC/BS of Texas without any problems. > ************************************************************************ > ************** > > Some alternatives are as follows: we have billed initial evaluations but > the initial evaluation are not billed as 314.00 or 314.01 since the > diagnosis typically is not complete and the concerns were not specific > to ADD/ADHD. We code based on signs and symptoms, Forgetfulness (780.93 > memory loss), Lack of coordination (781.3). We also have used 'Secondary > Diagnosis' codes as primary with some carriers without problems, i.e. > V40.0 Problems with learning, V61.29 Parent-Child problems, other, > V62.81 Interpersonal Problems, NEC, V40.3 Behavioral Problems, V62.3 > Educational Circumstances - Dissatisfaction with school environment. > > BCBS has accepted some of the secondary dx codes as primary but not all. > Most other insurance carriers accept the secondary as primary. Cigna is > the only carrier that I have had that repeatedly denied all secondary Dx > codes as a secondary and they needed a primary dx code. > > Remember, you are a provider of service. You are not an insurance > carrier, you do not write the insurance benefits or coverage rules. If > patients and families get upset at you, redirect the anger toward the > insurance carrier. "I understand your upset, however I must follow the > rules that are set by YOUR insurance carrier. I did not write the > insurance policy, your insurance carrier did. Therefore, you can take > the issue up with the insurance carrier or with the Texas Department of > Insurance. As the insured individual you have more rights under the law > then I do as the provider of service to appeal the decision of the > carrier." > > Hope this helps, > > Take care, > > Kevin Perryman > Kerrville, Texas > (830) 896 - 2758 > > > > -> -----Original Message----- > -> From: [mailto:] > -> On Behalf Of Ajey Godbole > -> Sent: Tuesday, August 03, 2004 10:24 PM > -> To: > -> Subject: Fw: BCBS not paying for ADHD > -> > -> > -> ----- Original Message ----- > -> From: Ajey Godbole > -> To: > -> Sent: Tuesday, August 03, 2004 10:23 PM > -> Subject: BCBS not paying for ADHD > -> > -> > -> I was informed by my billing manager that BCBS of Texas is > -> not paying the practice for a patient with ADD (without H) I > -> have seen 6 times in the office already. Apparently they and > -> a lot of other insurance companies in Texas are not paying > -> for 'mental health' diagnoses if billed by a primary care > -> provider. They will only pay for these diagnoses if seen by > -> a 'mental health professional'. The subliminal msg. is: bill > -> for 'something else' and it will get paid. > -> > -> I wonder if any of you has run into this. I am drafting a > -> letter to send with an appeal of the denials and I plan to > -> fight it for months if necessary but my manager tells me it > -> is futile! > -> > -> =ajey > -> > -> ------------------------------------------------------------- > -> ---------- > -> questions: "" or > -> "http://www.pcc.com/lists/"; To unsubscribe: -> mail > -> "" with "unsubscribe" > -> > group. >