Wiki BCBS denied office visit 99214 with modifier 25

[aqibbashir@carecloud.com]

Hi,

I need some assistance with an issue regarding a denied office visit claim. I billed for office visit code 99214 along with preventive visit code 99393 to BCBS of Kansas, but the claim for 99214 was denied due to it being considered part of the preventive service 99393, despite having used modifier 25. I have already submitted medical records for a retrospective review, but the insurance company denied the claim again for the same reason.

I spoke with an insurance representative, who informed me that the denial was based on policy "Memo #1." I’ve attached the policy Snagit for reference. Below are the details of the diagnosis codes associated with the office and preventive visits:

• 99214: R43.0, L75.0
• 99393: Z00.129, Z68.52, Z71.3, Z71.82

Could you please provide guidance on how to address this denial? Thank you.

Attachments​

• 
  Memo.png
  176.7 KB · Views: 0

diagnosis codes, diagnosis coding

 

[TatyanaNegovan]

Resolution steps:
1) 99393 code with primary DX Z00.121 - Encounter for annual child exam with ABNORMAL FINDINGS.
2) 99214 is too high LOS for R43 & L75.0 conditions;
3) consider 99212 or 99213; based on time spent and documented for assessing patient's conditions;
4) MDM based: include medication via OTC or Rx, tests orders and referrals pertinent to R43 or L75.0
5) Check A&P part of documentation if provider documented objective for further work up of those conditions: endocrinological or neurological disorder suspected, etc.
6) For dispute, review tests results, if there are any abnormalities found relevant to patient's concerns;
7) Query provider on details

Kindest regards

diagnosis codes, diagnosis coding