# G0009 denial



## yumileggs78  (Sep 21, 2020)

Hello, everybody. I coded as below for pt. who has Humana medicare advantage and G0009 and 90670 got denied. Did I miss modifier? I hope someone can help me. Thank you very much in advance. 

G0438-got paid
99497-33-got paid
99213-25-got paid
99397-got paid
G0009-got denied
90670-got denied


----------



## trarut (Sep 21, 2020)

Crazy question but what diagnosis did you use on the pneumo codes?  If it's anything other than Z23, that's likely the reason for your denial.


----------



## yumileggs78  (Sep 21, 2020)

trarut said:


> Crazy question but what diagnosis did you use on the pneumo codes?  If it's anything other than Z23, that's likely the reason for your denial.


Thank you for your time to reply to my post. 
I did use Z23 for DX.....


----------



## jhendrix08 (Sep 21, 2020)

What denial codes and description is listed on the EOB? I'm actually really surprised that they paid for an office visit 99213 along with the AWV and a PE all in the same visit...


----------



## trarut (Sep 21, 2020)

Can you list out the line specific denial/remark/reason codes from the EOB for us?  That might help us help you


----------



## kathleeng (Sep 21, 2020)

yumileggs78  said:


> Thank you for your time to reply to my post.
> I did use Z23 for DX.....


We are receiving the same denials but from Medicare. DX also Z23.


----------



## yumileggs78  (Sep 22, 2020)

kathleeng said:


> We are receiving the same denials but from Medicare. DX also Z23.


We got paid with the same coding above from Medicare for other different pt. though.


----------



## yumileggs78  (Sep 22, 2020)

trarut said:


> Can you list out the line specific denial/remark/reason codes from the EOB for us?  That might help us help you


Thank you for your time to reply on my post. denial/remarks are N115 N386 CO-96. I am a newbie to billing part, I appreciate for your help.


----------



## yumileggs78  (Sep 22, 2020)

jhendrix08 said:


> What denial codes and description is listed on the EOB? I'm actually really surprised that they paid for an office visit 99213 along with the AWV and a PE all in the same visit...


Thank you for your time to reply on my post. denial/remarks are N115 N386 CO-96. I am a newbie to billing part, I appreciate for your help. 
Yes, we usually get paid when medical necessary e/m service is done separately during the wellness visit.


----------



## NLCrew (Sep 22, 2020)

yumileggs78  said:


> Hello, everybody. I coded as below for pt. who has Humana medicare advantage and G0009 and 90670 got denied. Did I miss modifier? I hope someone can help me. Thank you very much in advance.
> 
> G0438-got paid
> 99497-33-got paid
> ...




If you are using UB04 form, you need to use the Condition Code for A6, revenue code 636 for Pneumonia/Influenza Vacc and revenue code 771 for administration of vaccine.  Hope this helps!


----------



## trarut (Sep 22, 2020)

yumileggs78  said:


> We got paid with the same coding above from Medicare for other different pt. though.



Was it the same exact combination of CPT/HCPCS/ICD-10 + modifiers?  And was it also a Humana MA plan that paid the other patient?  

To be perfectly honest, I would simply call Humana and ask for more information about the denial and ask them to direct you to the exact policies they are basing the denials on.  While I don't see any CCI edits for the codes you've billed, it would appear that the vaccine is caught up in the wellness visit or the preventative.  (I'm still not sure how all three of those visits are being covered but I'm lucky to be in a specialty that doesn't deal with wellness and preventative visits.)

Hopefully someone else can provide a better answer on this one but sometimes, you just have to make a call when it comes to billing issues.


----------



## Cynthia Hughes (Sep 22, 2020)

yumileggs78  said:


> Hello, everybody. I coded as below for pt. who has Humana medicare advantage and G0009 and 90670 got denied. Did I miss modifier? I hope someone can help me. Thank you very much in advance.
> 
> G0438-got paid
> 99497-33-got paid
> ...


Hi,

Perhaps 11 months have not passed since the patient received the other pneumococcal vaccine? This could cause a denial as the patient is eligible for the 13-valent vaccine one year (or 11 full months) after receiving the 23-valent vaccine. The remarks indicate that the charges were denied based on Medicare coverage policies so that is just a guess.

Cindy


----------



## yumileggs78  (Sep 23, 2020)

Cynthia Hughes said:


> Hi,
> 
> Perhaps 11 months have not passed since the patient received the other pneumococcal vaccine? This could cause a denial as the patient is eligible for the 13-valent vaccine one year (or 11 full months) after receiving the 23-valent vaccine. The remarks indicate that the charges were denied based on Medicare coverage policies so that is just a guess.
> 
> Cindy


Thank you very much for your post again. I will look into that. Have a nice day.


----------



## yumileggs78  (Sep 23, 2020)

trarut said:


> Was it the same exact combination of CPT/HCPCS/ICD-10 + modifiers?  And was it also a Humana MA plan that paid the other patient?
> 
> To be perfectly honest, I would simply call Humana and ask for more information about the denial and ask them to direct you to the exact policies they are basing the denials on.  While I don't see any CCI edits for the codes you've billed, it would appear that the vaccine is caught up in the wellness visit or the preventative.  (I'm still not sure how all three of those visits are being covered but I'm lucky to be in a specialty that doesn't deal with wellness and preventative visits.)
> 
> Hopefully someone else can provide a better answer on this one but sometimes, you just have to make a call when it comes to billing issues.


Thank you very much for your reply. Have a good day.


----------



## yumileggs78  (Sep 23, 2020)

yumileggs78  said:


> Thank you for your time to reply on my post. denial/remarks are N115 N386 CO-96. I am a newbie to billing part, I appreciate for your help.


Thank you for your time to reply to my post. Have a nice day.


----------

