06/27/2022

Healthfirst-Correct Billing 20550, J2920 and J1100 along with CPT 99213

We treated a HealthFirst patient and basically performed an Injection (20550, LT/ J2920, A6/ J1100, A6) Associated with Dx: M72.2/ M77.42/ M79.672 and M77.32 We also billed for an Evaluation and Management (99213, 25) for a separately identifiable diagnosis at a different anatomic site (M21.6X1/ M21.6X2/ M67.01/ M67.02/ R26.2) THE WHOLE CLAIM WAS DENIED (PROCEDURE AND VISIT) WITH DNIAL REMARK CODE : CO-185 (Blank Contracted Provider Program Not Valid For Authorization Translation: The provider program (location) that was entered on the authorization and billed against is not setup for the level of care and/or the CPT code that was billed, including modifiers.)

If you are in network with the patient’s Health First plan, customer service should be contacted to dispute the denial. For services provided in an office setting, Health First does not require referrals for authorizations for common services such as office visits and injections. It is not common to see this denial for a participating provider.

If you are out of network with the patient’s plan, the claim was denied by Health First because the services that were provided to the patient were not authorized by the managed care plan. If prior notification was obtained from Health First, the details listed in the authorization should be reviewed, such as:

• Are the rendering or billing provider on the claim the same as what is listed on the authorization?
• Are there any differences in the procedure or diagnosis codes that were pre-certified compared to what is on the claim?
• Were services set to be provided in a specific office or clinic location?

If there are no discrepancies between the information authorized to what was billed, this should be disputed or appealed with Health First.