We Know Medical Billing

A SSIMED Success Story!

One of our oncology clients performs blood transfusions for their patients who become anemic as a result of their chemotherapy treatments. This client decided for the convenience of their patients, to perform the transfusions at their office, rather then making the patients visit a hospital.

The procedure codes the client billed to Medicare were:

• 90780/90781 (IV Infusion for Therapy and Each Additional Hour of Time Spent Overseeing the Procedure)
  
• J7050/J7051 (Saline) linked to a diagnosis of V59.01 (Whole Blood Donor)

Medicare denied the claims stating they lacked necessary processing information (denial code: CO-16).

SSIMED Billing Supervisor Pam Lederer and Team Leader Donna Walaszek, met with the client to clarify which services were being performed and to determine which of those were billable. The client indicated that they were performing a blood transfusion but were only billing for the infusion of the saline. (Saline is administered simultaneously as a necessary component of this procedure.)

Pam and Donna advised the client to bill the blood transfusion (36430) along with the original procedures (infusion and saline) and to link them to the appropriate anemia diagnosis (285.0) with a secondary diagnosis of cancer. SSIMED assured the client that they would exhaust all efforts pursuing their reimbursement.

The corrected claims were submitted to Medicare. Reimbursement was received for the blood transfusion however, the IV infusion therapy and saline were denied as not medically necessary (denial code: CO-50). Medicare didn’t understand why the practice was infusing saline in someone with anemia.

Donna called Medicare Provider Relations to inquire where she could find Local Medical Review Policies (LMRPs) for billing the complete service that the client was performing. Medicare stated that they did not have a local policy or current publication that outlined the correct billing procedure when billing for blood transfusions on chemotherapy patients in an office setting. Medicare advised Donna to write to Freedom of Information regarding this situation.

Donna did so and received a favorable response from HCFA. The letter stated that Connecticut Medicare does not have a LMRP regarding these procedure codes but “should cover these services”. They suggested that Donna appeal the denied services and attach a copy of their response.

The end result was complete success for everybody!
Medicare now reimburses medical practices for this grouped procedure thanks to the tenacious work of our Billing Team. Our oncology client was ecstatic with the outcome. Their reimbursement for this procedure has increased, in turn raising their monthly revenue.