Practice Management

  • 1.  93325 - Prior Authorization

    Posted 10-12-2018 09:52
    ​Hi there -

    We've been seeing a lot of denials for the 93325 portion of the fetal echo exam. Has anyone been successful with the providers at BCBS and Connecticare? BCBS keeps referring us to Availity and Availity says they don't do prior auths for 93325 because it's a secondary code which only requires authorization if the primary ultrasound code also requires it. Connecticare doesn't know what a fetal echo is, forwards them to NIA and denies all of them as stress echocardiograms.

    TIA!




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    Kimberly
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  • 2.  RE: 93325 - Prior Authorization

    Posted 10-13-2018 13:02
    This appears to me like one of those situations you need to speak directly to the medical director of the plan.  Color flow (93325) is not considered part of fetal echocardiography, but as we all know is commonly used and should be approved when authorization is needed and documentation of necessity is submitted.  Additionally, it is important to document use of color flow doppler within the report.

    Coding questions 1808 and 1574 address this a bit.

    Yet again, this is a reason for constantly having a person in your practice meeting medical directors for your top 5 plans at least twice a year to develop a relationship to get matters such as these handled rapidly.




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    Brian Iriye
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  • 3.  RE: 93325 - Prior Authorization

    Posted 10-13-2018 23:12
    Agree with Brian. Also, make sure that your contract with that payer allows for billing of 93325 in addition to 76825/76826 as some providers have reported that their contracts prohibit billing for 93325 when a fetal echocardiogram is done. If your contract does not have this limitation, please let us know to explore other avenues we can assist you with.

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    Fadi Bsat
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  • 4.  RE: 93325 - Prior Authorization

    Posted 10-15-2018 08:34
    Good Morning
    Yes, we also just participated in recommendations to Aetna in regards to their Color Doppler for Echo practice bulletin.  Many payers have incorrect codes listed (pediatric or adult codes) as indications for Color Doppler, and this is why when billed as with a "fetal" indication or "O-code", do not appear to be covered or get flagged for a denial/edit process.  As Fadi & Brian mentioned, contact the Medical Director, attempt to obtain the policy bulletin and review the codes.  Then you can appeal.  Aetna bulletins are available on-line, if you want a "payer" resource to provide BCBS or Conneticare. Also, yes, as Brian noted, please reference our Coding Resources and take a look at the questions for additional help.

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    Vanita Jain
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  • 5.  RE: 93325 - Prior Authorization

    Posted 10-22-2018 11:41
    ​Thank you all for your helpful responses -

    I've called Anthem BCBS and spoke with a supervisor who reviewed the discrepancy between what Availity is saying and what their denials system identifies and confirmed that there is no limitation on billing 93325 with 76825. She assured me that they're working to correct the issue in their IS. Unfortunately because they've already been denied, each claim needs appeal, so off to work I go.

    Connecticare still thinks that a 93325 cannot be billed with anything other than a 9xxxx series code as primary. Being part of a larger corporation with the benefit of centralized AR, I'm forwarding that issue to my physician representatives for follow-up with their contacts there.

    Again, many thanks.

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    Kimberly
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  • 6.  RE: 93325 - Prior Authorization

    Posted 05-06-2019 10:06
    ​Just as a follow-up to this - I escalated it to our physician partners at BCBS 12 separate times. Persistence paid off and BCBS finally agreed that they've been denying our 93325 (and often the US code that goes with it) due to an error in their processing department. All Fetal Echo from our office have been resubmitted and paid through 2018. Budgets will be fun next year.

    Thanks for all of your help!
    Kimberly

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    Kimberly Montero
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