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45380-59 payment not allowed under OPPS/APG guidelines

Heidi Posted Fri 31st of August, 2018 12:18:15 PM
I'm running into some issues without our facility claims denying; our facility (Ambulatory Surgical Center) claims are denying payment of the second line when we bill both 45385 and 45380-59 stating payment is not allowed under OPPS or APG guidelines. We’ve appealed and they’re denying our appeals, even with med recs. Do you happen to have anything in writing we can send with the appeals showing both codes are payable? (the phys clms pay without issue…it’s just the abulatory surgical center clms); thanks!
SuperCoder Answered Mon 03rd of September, 2018 07:53:24 AM


We need some further clarification on the query:

What does facility claim mean here?

Kindly send us the explanation of benefit (EOB) to the below mentioned address with "Attention to Coding Team". or you can contact (866)228-9252.

Thank you

SuperCoder Answered Tue 04th of September, 2018 10:50:15 AM

As per the received EOB, please find below the reasons of denial:

  1. Per reason code CO97 - Provider services has already been paid in the previous claims or may be inclusive in another service.
  2. Per reason code OA209 - It seems provider has collected payment (coinsurance or deductibles) from the patient. If so, this may be the reason for adjustment by the payer. 

Request you to get in touch with your payer for rectification purposes.

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