Internal Medicine Coding Alert

Question: When an insurance company denies a claim, stating a procedure is inclusive to the primary procedure, but it is not, what step can we take to easily and clearly show this?

Colorado Subscriber

Answer: First, double-check the National Correct Coding Initiative (NCCI) edits to make sure Medicare doesn't bundle the procedures. Also, if you used modifiers, be sure you used them appropriately. For example, you can't attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to a procedure code.
 
If you correctly reported the services, your practice should formally appeal the denial. Provide the insurer with documentation, such as NCCI edits and pages from the CPT manual, that supports your claim. Get the insurer's response in writing for your records.