CPT 76499 | DRMAPro 2 Main

Response To the Insurance Company Payment Denial:

Note: This information is for educational purposes and should not replace professional legal or medical advice.

Diagnostic Necessity of Radiographic Mensuration Analysis

Dear (adjuster),

In response to your denial for Diagnostic Radiographic Mensuration Analysis (DRMA), please be advised that this procedure serves as a vital tool in detecting spinal ligament injuries that are not visible to the naked eye or through standard imaging techniques. This advanced diagnostic approach is essential for:

Accurate Diagnosis: Utilizing specialized software designed to measure intervertebral movements to identify ligamentous instability, providing precise data that standard X-rays may not reveal and that the human eye cannot detect.
Informed Prognosis: Identifying ligament injuries allows healthcare providers to better predict patient outcomes and potential complications.
Comprehensive Patient Education: With detailed diagnostic information, physicians can effectively communicate the nature and severity of the injury to patients, facilitating informed decisions about their health, treatment plans, therapies, restrictions and limitations of functional activities.

Impact on Treatment Planning

While the primary treatment plan may not change post-analysis, the new diagnostic insights gained are invaluable for:

Adjusting Therapeutic Approaches: Understanding the specific ligament damage may lead to modifications in therapy intensity or duration.
Implementing Activity Modifications: Patients may need to alter daily activities to prevent exacerbation of the injury.
Considering Surgical Interventions: In cases of significant instability, surgical options might be explored.

Therefore, the argument that reimbursement should be denied if the treatment plan remains unchanged fails to recognize the procedure's role in enhancing diagnostic accuracy and patient management.

Legal Precedents Supporting Reimbursement

Several arbitration cases have set precedents for the reimbursement of radiographic mensuration analysis:

Case Example: In Northern Physical Therapy Chiropractic & Acupuncture, PLLC & Geico Ins. Co., the arbitrator found that ligament laxity analysis, billed under CPT Code 76499, was justified. The decision highlighted that the analysis provided objective data on spinal injuries, requiring significant time and expertise, thus warranting separate reimbursement.

These cases underscore the recognition of radiographic mensuration analysis as a distinct and necessary diagnostic service, meriting appropriate compensation.

Radiographic mensuration analysis is a critical diagnostic tool that uncovers injuries not detectable through standard imaging or visible to the human (naked) eye, thereby enriching patient care and informing treatment decisions. Denying reimbursement based on the absence of changes in the treatment plan disregards the essential diagnostic contributions of the procedure. Legal precedents affirm its validity and the necessity for appropriate reimbursement.

In conclusion, I formally request that [Insurance Company Name] promptly reassess and approve the reimbursement for CPT code 76499 as previously submitted. Failure to address this matter satisfactorily within [specific timeframe, e.g., "30 days"] will compel me to escalate this issue to the appropriate regulatory authorities and consider all available legal remedies to ensure compliance with applicable insurance regulations and fulfillment of contractual obligations.

I trust that [Insurance Company Name] will give this matter the immediate attention it warrants to resolve this dispute amicably and expediently.

Sincerely,

[Your Name]

Unlisted procedure

You may encounter an insurance company or adjuster that contends that radiographic mensuration analysis is non-billable if the procedure doesn't lead to modifications in the treatment plan. At DRMAPro2, we agree. However, this perspective overlooks the critical diagnostic value of such analyses, especially in identifying conditions which may not be detectable through standard imaging techniques and identifying conditions which may not be detectable to the human eye …as “Alteration of Motion Segment Integrity” (AOMSI).

Chiropractic use

Some healthcare providers, particularly chiropractors, may utilize this code when performing detailed measurements from radiographs, like ligament laxity analysis, which is sometimes referred to as "diagnostic or computerized radiographic mensuration analysis.". Chiropractors report billing $540 per spine region.

Verification needed

Please note that we do not provide billing or coding advice. The information shared is based on reports from other users and is for informational purposes only. Always consult with your billing department or a certified coding specialist to determine the appropriate use of CPT code 76499 for your specific circumstances.

Key points about CPT code 76499:

The CPT code for radiographic mensuration analysis is typically considered to be 76499. This is classified as an "unlisted diagnostic radiographic procedure" and is often used when a specific code for the detailed analysis of measurements from a radiograph isn't available.