denials

  1. H

    Wiki Ins Appeal Letters

    I’m new to this specialty (DPM or Ortho surg) and would appreciate your help with appeal letters. If you have any templates or useful resources—like websites or tips—you could share, I’d be so grateful!
  2. ahrx13

    Wiki Termination of insurance appeal

    We've been getting multiple claim denials lately stating that the member's coverage was terminated, usually just a few days before the date of service. We go online to confirm their active status and call for benefits before or on the date of service. We try to appeal the claim and state that...
  3. L

    Wiki Humana Mod -79 Denial

    Hi, I have noticed denials from Humana on procedures billed with mod -79 performed during the global of another procedure. Commonly seen on cataract surgery done on the opposite eye during the global period of the first eye. Practice is also billing with laterality mods. For example, first...
  4. M

    Wiki Ventral Hernia Repair Recoups

    Has anyone else been getting hit with Ventral Hernia repair recoups from UHC and Humana for 2023? Their reasoning is that we didn't provide "preoperative" hernia measurements (I think this is taking way too much liberty with the guidelines). Some reps have even said that it should be documented...
  5. G

    Wiki Group Psychotherapy Visits

    I work for a facility that frequently bills multiple, separate psychotherapy group visits per day for the same individual. For example, the patient attends a group visit at 10 am and will return later in the day for another meeting. Sometimes it's with the same facilitator and sometimes it's...
  6. K

    Wiki INCIDENTAL DENIALS

    THIS MAY BE A DUMB QUESTION BUT HERE IT GOES I HAVE BEEN GETTING DENIALS LATELY THAT ARE (N19) PROCEDURE CODE INCIDENTAL TO PRIMARY PROCEDURE. AETNA MEDICARE INSURANCE, THIS CLAIM IN PARTICULAR IS A E/M WITH MODIFIER 25, WITH 69210 OVER HAS BEEN PAID BUT NOT THE 69210, FOR ME TO APPEAL THIS...
  7. RaveenaS

    Wiki Humana Denial for Missing Hernia Modifier {Redacted Op Provided}

    Humana has sent a letter explaining the claim is denied for missing a required modifier to the primary procedure code. I've reviewed this so many times myself, with my coding team, and I've contacted Humana but the rep state they cannot provide any coding recommendation as they are not part of...
  8. A

    Wiki HELP!!! OPTUM - PAIN MANAGEMENT INJECTION DENIALS

    We have been having an issue of getting our pain management injections paid by Optum Lifeprint (ex. ESI, MBB, RFA, Joint, etc). Everytime we bill an injection, we get a denial stating that Optum requires a drug code to be associated with the claim. And here is the kicker: we don't buy the drugs...
  9. A

    Wiki 62321 and J1100 denial

    We have been receiving denials from Blue Shield for missing modifier on 62321 but J1100 is paid. Is J1100 included in 62321? or would I have to bill a 59 modifier on 62321?
  10. B

    Wiki Medicaid Denials

    Hello! I keep getting Medicaid denials for claims and the reason is that it says "Missing Billing Provider Taxonomy number". Well this denial just started happening after years of no issues before, also the billing provider and provider taxonomy numbers are the same, anyone else have this issue...
  11. J

    Wiki Claim Denial: Mutually Exclusive Procedures

    Hello, everyone! I am not sure if this is posted yet. But I have a quick question regarding denials and appeals for California. Recently, we have had a denial for mutually exclusive procedures: unbundling for the codes as follows: 17000 - L57.0 AKs 17003 - L57.0 AKs 17110 - B07.00 Plantar...
  12. G

    Wiki ESI 62321-62323

    Blue Cross claim denials when billing 62321 and 62323 together.
  13. F

    Wiki Lab denial

    So I have 2 separate claims for one patient. They both have 84443 (TSH), They were ordered by separate providers on separate dates but the lab results we're finished on the same date. We got a Medicare denial code 0A-18 ( duplicate claim on the same day). How do I go about billing them so they...
  14. C

    Wiki DME medicaid denials

    We have been receiving denials from our medicaid plans on our DME's such as L1902 and L3908, stating it is included in a global surgery package. We have never had this issue before. I have tried looking up changes to billing DME's but cannot find anything. I called the insurance and they can...
  15. KStaten

    Wiki Humana Denials: Why Does Humana Request Bilateral Modifier 50 for Non-Bilateral Body Parts?

    Hello Everyone. :) Does anyone else have issues with Humana denying injections for non-bilateral body parts (such as a left shoulder and right knee injected on the same visit) because they are requesting the bilateral modifier 50, rather than the correct LT/RT; XS modifiers ? Is there a way to...
  16. S

    Wiki SIJ/Medial Cluneal Nerve Stimulator Coding

    My pain management provider coded this procedure with 64555-51 (2 units), 64575, 64590 (2 units). Medicare denied the last 2 codes. Are the codes included in the primary? DX code is G58.9. Can anyone clarify this? Thanks in advance!
  17. M

    Wiki Denial of primary code when billed with +add on code

    Is anyone experiencing denials for the payment of a primary procedure, but receiving payment on the +add on code. Ex: 14301, 14302? This is Palmetto GBA in GA.
  18. B

    Wiki Telemedicine Telehealth Denials Aetna Texas

    Hi all, This is my first time posting, so I hope I'm in the right forum and also not repeating someone else's question. This question is specifically for Aetna in Texas but any feedback is appreciated. I am getting no where fast when trying to get reimbursement from Aetna for Televisits...
  19. K

    Wiki Billing TCM & G0506 Together

    Hello, Looking for some feedback on billing TCM and CCM code G0506 together. It's been brought to our attention that these are denying when billed together. Wondering if a simple -25 modifier would fix or if this isn't allowed. Can't seem to find any clear documentation in the guidelines. Thanks!
  20. H

    Wiki Denials for inpatient E/M when billed with non-manipulated fracture code

    We're getting a lot of denials for our E/M service when it's billed with a non-manipulated fracture code. For example 99221/57 with 27808 (Closed treatment of bimalleolar ankle fracture ; without manipulation). The E/M is clearly a 99221 we're attaching the proper modifier seeing this is a 90...
  21. D

    Wiki Urgent care dx denials

    Hello, I am hoping someone with UC experience can give some insight; at UC we do not have the facility to send labs for every dx. Certain dx require the cause of the dx, such as pneumonia (J12-15.X) or J06.9 "acute upper respiratory tract infection, unspec" wants the bacterial cause. We are...
  22. M

    Wiki BCBS denying E/M codes with 25 modifier

    I do billing for five different practices across Texas and am having an issue with BCBS. They are denying most E/M codes when we use the 25-modifier (to distinguish from other services rendered the same day). I've gotten dozens of these so far. I have read some info online from different...
  23. M

    Wiki Cms mm9911

    We recently began recieving other adjustments on our Medicare EOB's reason code CO237 with N700 Payment adjusted based on the EHR incentive program, N699 Payment adjusted based on the PQRS incentive program, N701 Payment adjusted based on the Value based Payment Modifier; are these not what...
  24. 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...
  25. T

    Wiki DEXA Denials from BCBS MI

    Hello, we are getting a TON of denials from our home plan BCBS here in MI when we bill the DEXAs (77080-77085). Per ICD-10 the screening code needs to be listed 1st and then the reason for the screening and then any findings. This is how we code. Example: PT is a 74 year old post menopausal...
  26. K

    Wiki Denial Rate Benchmarking

    We are in search of denial rate by specialty to benchmark with our practice. Since we are a surgery practice we are looking for where we might find denial rates for a similar denial rates. Can anyone point me in the right direction?
  27. L

    Wiki 11301 shave codes Medicare Denials

    Recently Medicare has been denying procedure codes 11300, 11301 etc... all the shave codes. We have never had an issue in the past not sure what is happening now. They are stating that it is not a covered service. We have sent path reports and physician notes and they still deny. Any insite...
    • LBernat7
    • Thread
    • 11301 denials dermatology medicare shave lesion
    • Replies: 11
    • Forum: Dermatology
  28. L

    Wiki Shave Codes being DENIED by Medicare

    Recently Medicare has been denying procedure codes 11300, 11301 etc... all the shave codes. We have never ha an issue in the past not sure what is happening now. They are stating that it is not a covered service. We have sent path reports and physician notes and they still deny. Any insite...
  29. N

    Wiki United Healthcare DME Supply Denials

    Our office is going crazy with these United Healthcare (Medicare Advantage Program) denials! I am hoping that someone else might be going through the same difficulty. We are a 3rd Party supplier/billing/coding company for DME supplies in nursing homes - generally when a patient finishes their...
  30. J

    Wiki Can I REBILL and Collect on a Chiropractic Case from four years ago?

    Can someone please tell me if I can legally submit new revised bills for a WC Case/FECA from four years ago? The Doctor says YES but FECA rules say NOT, so what should I do? Any input will be helpful I was hired to do Collections, Doctor did billing and coding so the files are considered problem...
  31. T

    Wiki Herceptin

    Is anyone getting requests for documentation for Herceptin, we send what they are requesting and Medicare denies it. It meets guidelines i'm just not sure what were doing wrong. Has anyone experienced this?
  32. L

    Wiki Denials on 90471 from Medicare Advantage plans

    Good afternoon everyone, Has anyone, working as a FQHC, received any denials from Medicare Advantage plans for immune administration code 90471?? We have 28 denials where they state the procedure code is invalid. There are 2 different scenarios where we got denied. 1. Patient came in to...
  33. C

    Wiki Denial from BCBS for dx code inconsistent with procedure code

    I work in a Neurology clinic with a physician who specializes in movement disorders. Yesterday we received 3 denials from Blue Cross with the Reason Code CO 11 attached, the diagnosis is inconsistent with the procedure. I coded the visits as follows: G20 (Parkinson's Disease) as the primary...
  34. C

    Wiki Medicare Denials for Screening Bone Mineral Density DEXA CPT 77080

    Hello, we are receiving denials for screening dexa scans CPT 77080 with diagnosis Z13.820 screening for osteoporosis. Per Medicare article MM5521, screenings are allowed every 2 years, but we are being denied. The denial is for NCD, as Medicare NCD 150.3 does not list the Z screening code...
  35. S

    Wiki Commercial Insurance ABNs

    What are the general rules regarding the use of ABNs for commercial insurance plans? If the insurance company denies payment for a service with a CO (Contractual Obligation) code, can we still bill the patient if they have signed an ABN in advance? Thanks for the input!
  36. U

    Wiki Billing Specialist job opening

    If anyone knows of someone interested in a position in billing, please have them send me their resume. The position will be posting charges/payments, working denials and patient a/r. My email is kbates@uasenc.com. We are located in Wilmington, NC. Thank you
  37. C

    Wiki 29823 with 29824

    29823 arthroscopy shoulder surgical with debridement extensive : is bundling with 29824 (mumford) I have used a modifier 59 and operative does support the debridement , however my denials are still upheld , I donot see any edits that say that its inclusive
  38. 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?
  39. M

    Wiki Asq denials

    We give our patients asq at well child exams and have recieved denials for them, have you recieved payment on them before?
  40. L

    Wiki Medicaid Denials - Newborn Daily Visits

    It appears that my office is receiving denials for CPT code 99462 & 99239 when matched with ICD-10 Z00.110 (health check for newborn under 8 days). Does anyone have another diagnosis that might be more appropriate?
    • LeaHarris
    • Thread
    • check days denials newborn z00.110
    • Replies: 7
    • Forum: Pediatrics
  41. H

    Wiki Multiple Medicare Denials for Medical Necessity

    I apologize ahead of time for my ignorance, I am still new to coding/billing and have learned on the job through trial and error. I received 3 pages of denials from Medicare for " these are non-covered services because this is not deemed a "medical necessity" by the payer". But the codes used...
  42. J

    Wiki 64721 with 64450

    can we code 64721 carpal tunnel release along with 64450, median nerve block injection? we keep getting denials on this. please advise. thanks!
  43. V

    Wiki Pain Management OP Clinic

    a couple of my Anes Docs also run the Pain Mgt Clinic here at the hospital, place of service is 22. We have a PA who does Pain Pump Analyze, 62368 and Pump Refill, 95990. We keep getting a denial on 95990 not paid in place of service 22. Someone told us to try 96522 also a refill but we get...
    • vworsham
    • Thread
    • anes denials pain pain management pain pumps
    • Replies: 2
    • Forum: Anesthesia
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