denial

  1. M

    Wiki Humana Mcr Diagnosis code issue

    When billing colonscopies/egds for our practice-physician orders colonoscopy for positive cologard (r19.5) pathology comes back nothing found. We obviously leave r19.5. Humana pays procedure but denies pathology for dx code issue. Why? We have never had issues with this. Physician orders egd for...
  2. M

    Wiki BCBS Denying Pathology Claims

    Has anyone been having issues with BCBS denying pathology claims since maybe June/July of 2024? We have denials and all they can say is since Avalon take over there are new guidelines- things such as k29.50, k21.00, and k22.89 cannot be coded together. Or k22.2 and k21.9 cannot be coded...
  3. J

    Wiki ZELIS HELP!

    Hi, so I am getting increasingly frustrated with Zelis coding denials. I keep getting "Procedure not compatible with diagnosis" denials. For example with closure gastrostomy surgery 43870, we are getting a denial for dx code K31.6 (fistula of stomach & duodenum). I have been using these codes...
  4. L

    Wiki Recoupment on 22633 if minimally invasive technique is used?

    Does anyone have any guidance on this situation? I am relatively new to spinal surgical coding and cannot find any guidance that indicates that a minimally invasive technique should be coded differently from the open? But we've received a couple post review recoupments saying that 22633 does not...
  5. A

    Wiki 49594 IP ONLY CPT Denial and documented size denial

    We are receiving a high volume of DNB requests from our billing dept asking us to review hernia coding, in addition to formal denials from payors. We have two main concerns 1) Addressing the IP ONLY review request and 2) The sizing is often noted in the "findings." However, the provider does...
  6. R

    Wiki Sublocade -- need help billing

    Hello Everyone - I work for a small clinic that tries to provide medical care to the homeless and drug using population. We mostly run off grants but we (now that I am working there) are trying to bill insurances for our services as well. I am fine billing basic E/M appointments. However, I...
  7. M

    Wiki Inappropriate Modifier?

    Hello, we've been experiencing some denials from a specific insurance (medi-cal contracted) stating inappropriate modifier as the denial reason. What would be appropriate here? Thank you!
  8. A

    Wiki Bundled Denial from BCBS on 97110

    I have a provider who performs peripheral nerve injections on a patient then the pt receives physical therapy by a PT on the same dos. Both services are documented separately and BCBS is denying the peripheral nerve injections as bundled to the physical therapy, stating the use of the modifier...
  9. R

    Wiki L2114 AUDIT, HELP!!

    I recently appealed a RAC audit for code L2114 that was orginally denied stating "documentation did not support that the billed custom-fitted item required more than minimal self adjustment at the time of delivery in order to provide an individualized fit, and included a detailed description of...
  10. A

    Wiki POST PHE BILLING OF AUDIO ONLY ENCOUNTERS

    Could someone assist me with the new policy for billing Audio-only visits (99441 - 99443) in an Independent clinic after the Public Health Emergency (PHE)? I've encountered denials from UHC and Medicaid-Mississippi stating that these services are no longer covered. I've reviewed their state...
  11. T

    Wiki Humana denial- Looking for guidance.

    I'm confused about forwarding billing onto patients with Humana. My practice is asking that I forward non-covered services to the patient when they are denied by humana plan. Since it is a Medicare replacement, can I do that? I thought it had to be written off because it is denied by insurance...
  12. S

    Wiki Code 11102 + 11103 Denying Under Physician's Assistant

    Medicaid plan through Banner University Family Complete Care is denying codes 11102 + 11103 with a PA on the claim stating "99353 AHCCCS P353: PROVIDER TYPE NOT ELIGIBLE." The claim pays however when we resubmit under an MD as opposed to the PA originally on the claim. This issue began in Jan of...
    • SamrPen
    • Thread
    • 11102 11103 ahcccs biopsy denial dermatology integumentary phycisian's assistant
    • Replies: 2
    • Forum: Billing/Reimbursement
  13. E

    Wiki Denial of exam with modifier -24

    Hello, If a payer (Humana) denies an exam with modifier -24 and we have sent in an appeal with documentation showing it is unrelated to the global period what recourse do we have or what can I cite to show that we have billed it correctly and met all the criteria and they are in violation...
  14. T

    Wiki Priority Health Unspecified DX Denials

    Is anyone else receiving denials from Priority Health when the diagnosis- even the very last dx on the claim is unspecified? I would love to connect with others who have this issue.
  15. L

    Wiki Column one and two, modifier inquiry

    Recently, our office visit 99213 with modifier 25 was denied saying that 99213 is a column two code included in column one code, 97597. What would be the appropriate modifier for this situation? Also, can anyone direct me on where to find the column one/two list?
    • Linki
    • Thread
    • column 1 column 2 denial modifer
    • Replies: 3
    • Forum: Modifiers
  16. J

    Wiki Aetna Medicare denying Venous Studies

    Aetna Medicare has started denying venous studies (CPT 93970 & 93971) due to frequency. They cite CMS LCD & Article as it only allows one per year. No other payers including Medicare are following the LCD. Any suggestions?
  17. C

    Wiki CMS 99358 (2022)

    Good morning, Do you have any tips on billing this code? Does it have to be on a separate claim to the actual face-to-face encounter? All services were rendered in 2022. Thank you
  18. L

    Wiki 93000 - EKG denial

    I'm getting rejection from Medicare, UHC for EKG code 93000 even when submitted with payable dx. The denial code is M80: Not covered when performed during the same session/date as a previously processed service for the patient. Is the any new NCCI for this code, 93000, if so, where I can find...
  19. L

    Wiki 99497-33 Denial

    Hello, everybody. I coded as below for pt. who has BCBS State Health Plan , secondary is Medicare and 99497-33 got denied by both insurance. Did I miss modifier? Spoke to BCBS Rep and was explained that advance care planning was bundled in to e/m service. I am a new biller hope someone can help...
  20. L

    Authorization Denials, Surgery

    Curious- Has anyone had surgery auth denials for final coding not being what was anticipated and auth'd prior to surgery that they've appealed successfully? Example: Surgery paperwork may states "Knee arthroscopy, diagnostic, meniscectomy" CPTs: 29870, 29881 called on/submitted for surgery...
  21. D

    Wiki 28470 not preformed

    Provider billed 28470x2 diagnosis: M84.374A After appealing with chart notes, UHC says that the chart notes do not support that the 28470 was preformed. Dispensal of pneumatic cam walker was documented and diagnostics were preformed to accurately diagnose the fracture. All of this information...
    • DrTomsFA
    • Thread
    • appeal denial fracture help ortho orthopedic podiatrist podiatry
    • Replies: 7
    • Forum: Orthopaedics
  22. M

    Wiki 29824 - Arthroscopic distal claviculectomy

    I am needing some help with an appeal. The insurance is Humana Medicare Choice PPO. I billed 29824 and 29826. First, they requested medical records before processing the claim. I submitted the records. They denied the claim stating the services were not documented in the medical record. I...
  23. T

    Wiki Unbundling

    Can I get some insight on unbundling services? I have a couple of scenarios. 1. 64633-50, 99070, S0020, J3301 ( RF Ablation with use of lidocaine, Marcaine, and Kenalog. 99070 was billed for misc supplies) 2.99203-25 62321, 62323, 99070, J3301, Q9966 (New patient visit where a cervical ESI and a...
  24. A

    Wiki Denial dexa claims

    I have a 72 male patient with United healthcare Medicare plan coming iN did screening dexa. The insurance first denied the screening code, then denied it shin when we tried to bill as diagnostics dexa. Really don’t know what’s wrong with it....
  25. K

    Wiki Critical Care Denial

    I'm working on a denial for a patient that saw two of our intensivists in the ICU on the same day. Dr. A saw patient 1st for just under 74 minutes so we billed 99291; Dr. B saw patient second so we charged 99292. This is how we have always billed critical care and we've had no issues with...
  26. E

    Wiki Modifier 55 NIGHTMARE

    Can anyone please tell me how to get a claim paid when using modifier 55? We had a patient who came in as post operative management care after having ORIF on tibia out of state. According to Medicare guidelines you are to bill the procedure using date of procedure with modifier 55 and place of...
  27. R

    Wiki Assistant Surgeon Billing

    I work for an orthopedic surgeon who does predominantly worker's compensation billing. Recently, we have gotten denials from some of the insurance carriers denying the assistant surgery due to "the surgeon must specify what specifically the assistant performed." We have never heard of this...
    • rebeccadb
    • Thread
    • additional documentation assistant surgeon denial
    • Replies: 11
    • Forum: Orthopaedics
  28. E

    Wiki Denial from Primary

    If a patient has two insurances and the primary denies (denial is appealed and upheld), do you have to bill the secondary insurance? A co-worker was told to adjust and to not bill the secondary at all.
  29. S

    Wiki Need help why Medicaid-AL been denying CPT 36902

    Hello, we billed 36902 by itself and MCD-Alabama has been denying it for " M49: Missing/incomplete/invalid value code(s) or amount(s). N59: Please refer to your provider manual for additional program and provider information." ANyone help me please...Thank you.
  30. K

    Wiki Anthem BCBS Denying 2nd Eye Cataract Surgery

    Is anyone having issues with Anthem denying/rejecting the second eye cataract surgery within global of the first eye as "modifier used is inconsistent with procedure?" 66984 - RT w/ ICD-10: H25.811 66984 - 79, LT w/ ICD-10: H25.812 We have never had issues before and cannot get through to a...
  31. M

    Wiki 58544 and 58700 denial?

    Has anyone had any issues billing these codes together? Are they being denied as inclusive to each other?
    • mpizor
    • Thread
    • 58544 58700 denial inclusive
    • Replies: 1
    • Forum: OB/GYN
  32. X

    Wiki 93015 Medicare Denial

    Hi everyone! Our practice is new to cardiology coding. We are continuing to get Medicare denials for CPT code 93015. The denial code is N-182 "This claim/service must be billed according to the schedule for this plan." I appreciate any and all support, advice, or assistance! Thanks...
  33. G

    Wiki Denials from medicaid

    Hello, I have run into an issue with Medicaid stating that 1) L21.0 has an age limit. This I don't understand because this is a code for Dandruff and anyone can get dandruff at any age? However there are no other appropriate codes to assign to this patient from the medical record. 2)...
  34. C

    Wiki Federal BCBS rejecting 62323 and 62321

    We have been having issues all of 2017 with FEP denying 62323 and 62321. First for medical records, and then when we send them, that our providers are not eligble to perform the service. 62311 and 62310 we never had any issues with nor are we having any issues with any of our other injection...
  35. E

    Wiki Z80.0 clinical edit error BCBS Michigan

    Anyone experiencing denials for Z80.0 with BCBS? I've run into several plans that are denying Z80.0 (family hx colon cancer) as an invalid ICD10 code for high risk screening colonoscopy. I've talked with provider services, reported the issue and believe since Oct 1st they have an error in their...
  36. L

    Wiki Uhc & emg 95886 add on denial for max qty

    I have done everything I could to research this further. No matter how I bill this whether it is 1, 2, 3 or 4 units on line line item it denies. It does not do this for ANY OTHER carrier. This billing for up to 4 units per line item was acceptable until 2015- mid 2016, then late 2016-early 2017...
  37. G

    Wiki Working Medicare without Medicare FISS DDE system

    Does anybody here have any advice for working Medicare denials when you don't have access to the FISS DDE system? My practice is having a terrible time getting denials fixed. Every time we resubmit something, it will get denied as "M80" which is essentially a duplicate. Medicare describes it...
  38. M

    Wiki HELP!!!! Hopice/Home health billing!

    I work for a Home Health agency and have billed claims for a patient beginning on 5/3 the patient was discharged from Hospice on 5/2 the patient's insurance (Humana) has denied the claims stating "due to the fact that the patient was under hospice care." I have appealed the decision showing that...
  39. J

    Wiki Denial Billing secondary with G code.

    I need help, keep getting secondary denials because of the g code used when billing medicare as primary. Secondary denies because of the g code but we must use that when billing medicare, tried billing secondary without the g code but then it denies because it doesn't match the primary amounts...
  40. T

    Wiki BCBS FL denials for B20 (HIV)

    Is anyone else having an issue with BCBS of FL denials for diagnosis B20 (HIV)? They think that this is an inactive code as of 2017 - but I have checked CMS' site and CDC listing of ICD-10 and both show it as valid for this year with no planned addenda for the April 1st release either.
  41. daedolos

    Wiki Noridian Medicare denial

    I've been assigned research on a claim denial for reason code "CO-50" = non-covered services not deemed necessity by payer. Patient came in for neck pain and doctor examined and applied trigger point injection in the posterior aspect of the neck then prescribed physical therapy. However, the...
  42. Y

    Wiki CARC and RARC books

    I need to find a good set of books that outline the CARC and RARC codes and rules. Also, any other books for working through rejected and denied claims would be helpful as well. Any suggestions? Thanks
  43. H

    Wiki 76942 (ultrasound guidance) denied with nerve block

    Hi All, Ultrasound guidance (76942) is being denied by Oxford when billed with a nerve block code (64413, 64445, etc.). We have tried to appeal saying you need the guidance to ensure precision of the needle however, they are still denying it. :mad: Anyone run into this problem and found a...
  44. B

    Wiki Medicare denying Ultrasound Guidance used with Regional Block Placement

    Since January, CMS has been denying about 85% of our claims for ultrasound guidance 76942-26. Our anesthesiologists use ultrasound guidance when placing nerve blocks for post-operative pain control (sciatic/femoral/etc). Some of our appeals have resulted in the claim being reprocessed, but...
    • Billing500
    • Thread
    • 76942 anesthesia denial nerve block ultrasound guidance
    • Replies: 3
    • Forum: Anesthesia
  45. L

    Wiki Denial of multiple units of lesion excision (same CPT)

    We've recently started to see denials for excisions (same CPT) on the same claim. For example, 11403 x 3 units. Sometimes 1 unit will pay and other times none will pay with a message that the modifier used is incorrect or missing. We were able to get these paid until now with -76-59 on the...
  46. K

    Wiki Global maternity

    The patient was seen an excess of 7+ visits and then the c-section with post partum visits. Has anyone ever had an insurance company deny billing the global with the post partum because her plan will be termed prior to her global post partum completion date?? 6 weeks post partum and her...
    • Kholloway
    • Thread
    • denial global maternity insurance billing post partum
    • Replies: 5
    • Forum: OB/GYN
  47. L

    Wiki NCV denials from Medicare

    We are seeing an increased number of denials from Medicare for NCV testing (95911-95913) when billed alone (without the EMG). The denials state 'not deemed a medical necessity'. Dx codes used are included in the LCD. Anyone else having this problem?
  48. A

    Wiki do you need a modifer when using 97032

    I have just received a denial on a claim that I submitted to Tufts. I am working for a chiropractor and I have used 97032 before with no modifier used and now I get the denial CO-182 meaning Payment adjusted because the procedure modifier was invalid on the date of service. This has never...
  49. M

    ICD-10 DX for smoking cessation

    I am having some trouble with Medicare paying 99406 or 99407 when billed with E/M code using Dx F17.210. The denial is for "not medically necessary" Any suggestions? I appreciate any help Maru
    • mquiroz
    • Thread
    • code denial f17.210 medically suggestions
    • Replies: 7
    • Forum: ICD-10
  50. J

    Wiki Home Health

    Can anyone help me with this? If a patient is being treated with Home Healthcare and the referring physician authorizes and or signs the Plan of Care but it is not filed to insurance and is not timely filing, can we A) still bill for denial or B) can we file for the re-certification even thought...
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