Wiki 99212 denial

[Howard1Derm]

We are a dermatology office in NC. We billed a patient's BCBS State Health Plan using CPT code 99212 (modifier 25 used, ICD 10 codes used L73.8 and L57.8) and CPT code 17110 (Modifier 59 used, ICD 10 code used B07.8). They denied 99212 using the standard modifier 25 denial “CO97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.” As usual we appealed it and they upheld their decision and stated this was the final level of appeal. On the denial letter they included a direct person for us to contact and we spoke with them. Per their response “because we did not prescribe anything for either of the codes used with the 99212, we couldn’t bill it." When pushed they stated "that's just their guidelines." Per AMA guidelines 99212 does not require anything being prescribed, it is defined as a straightforward visit. Also on the denial letter it basically states they do not care about AMA guidelines. We contacted AAD about this and are waiting on a response. But my question is can commercial insurances companies just go by their own guidelines for reimbursement? Is there not a standard of guidelines across the board they must use? Has anyone else experienced this?

 

[thomas7331]

Yes, commercial insurance plans can write their own reimbursement rules. If your provider is contracted with the insurance company, there most likely is a clause in the contract that says that your provider agrees to abide by those policies. If you disagree with them, then you can either choose to terminate the contract or can try to negotiate a new contract that gives your provider an exception to the particular policies that you don’t agree with.

 

[rachaelwilleford]

We are a dermatology office in NC. We billed a patient's BCBS State Health Plan using CPT code 99212 (modifier 25 used, ICD 10 codes used L73.8 and L57.8) and CPT code 17110 (Modifier 59 used, ICD 10 code used B07.8). They denied 99212 using the standard modifier 25 denial “CO97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.” As usual we appealed it and they upheld their decision and stated this was the final level of appeal. On the denial letter they included a direct person for us to contact and we spoke with them. Per their response “because we did not prescribe anything for either of the codes used with the 99212, we couldn’t bill it." When pushed they stated "that's just their guidelines." Per AMA guidelines 99212 does not require anything being prescribed, it is defined as a straightforward visit. Also on the denial letter it basically states they do not care about AMA guidelines. We contacted AAD about this and are waiting on a response. But my question is can commercial insurances companies just go by their own guidelines for reimbursement? Is there not a standard of guidelines across the board they must use? Has anyone else experienced this?

It's not just commercial plans. Medicare, as shown in previous payment rules, can choose to accept AMA guidelines (CPT coding) or make their own. Take prolonged services for example. They didn't like how the time period was applied so they made their own code. Commercial plans can choose to apply their own rules for reimbursement as well.