Medical Necessity Denials

Question: We have a doctor that is billing Medicare for 97032-GP: “application of modality to one or more areas” and Medicare is denying as not medically necessary. Is having the patient sign an ABN the only way to get these paid?

The doctor obviously feels it is medically necessary. Any suggestions?

Answer: I think a little more research is in order.

First, review the CCI edits for 97032. It is not allowed with several other codes that would trigger a medical necessity denial.

Depending on the purpose of the treatment, Medicare may deem it experimental. Then you do indeed need an ABN.

You can try to appeal with appropriate documentation and clinical guidelines attached, although Medicare is unlikely to change its mind about something it already has ruled on.

Here is some other guidance that might apply, depending on why the physician is doing the service:

• https://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp

• https://www.apta.org/AM/Template.cfm?Section=Home&CONTENTID=42760&TEMPLATE=/CM/ContentDisplay.cfm

• http://www.highmarkmedicareservices.com/policy/partb/z1/z53a.html

Whoever sold the physician the equipment he is using may also have insights.