As paid vs. as it should have been
| Ln | Code | Description | Paid | Should be | Variance | Result |
|---|---|---|---|---|---|---|
| 1 | 72148 |
MRI, lumbar spine, without contrast material
M54.50 · Low back pain, unspecified
|
$191.72 | $191.72 | — | Correct |
Determination
Reviewed with no variance. Every line was paid at the allowable on file.
How it was coded
Remedy: None — the claim was billed and priced as the record supports
A repeat study of the same region inside 90 days, which is what put it in the batch. CPP-070 v1.3 allows it where the record documents a change in clinical status, and the record does.
Prior authorization
Texas HB 3459 exempts a provider whose prior-authorization requests were approved at or above the statutory rate from having to obtain them for the qualifying service. This provider holds that exemption for advanced imaging, so the absence of an authorization is not an authorization gap. CPP-085 carries the state variation; the same claim in Florida would have needed one.
Policy applied
Knowledge CenterSets the condition a repeat study of the same region within 90 days has to meet, and carries the Texas variation on site of service
No source document for v1.3 is in the index, so this policy can be cited here but not quoted. Upload it.
Coverage on the date of service, and the re-verification at audit
v6.1 was extracted from CPP-080_eligibility-enrolment-retroactive-termination_v6.1.md. Passages are quoted only on the policy the finding rests on.
Carries the Texas gold-carding exemption that makes the missing authorization a non-issue
v3.4 was extracted from CPP-085_prior-authorization-post-service-review_v3.4.md. Passages are quoted only on the policy the finding rests on.