Wiki Denial

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solocoder

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Can anyone give me a little more insight into what this Claim Adjustment Reason Code means: Coverage/program guidelines were not met or were exceeded.

Doctor removed 2 fibromas from two separate places by two incisions on the same foot. Humana PPO paid one, denied the other. This was the reason given.
Per CCI edits, 4 units per day are allowed.
 
2 fibromas from two separate places by two incisions on the same foot

Hi, I am going to go with my gut feeling with this without actually making the phone call to Humana.
I am betting that since both procedures probably had the SAME diagnosis code because they were from the same foot, they are paying one and denying the other. Yes, I read the "exceeded" part - but I also get that too with many path and lab denials. That adjustment denial code "personally" is similar to - prove it us that this really happened. I would at this point send the operative (or perhaps office visit/procedure note), and if possible the pathology report(s) supporting both specimens that were submitted for review. I know that certain POS (place of service) aren't required to submit for a pathology review, but I'm just hoping that it may be an extra edge for you to winning your denial!
Hoping this helps,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB
Anesthesia, Pathology, & Laboratory Coder
 
What codes, DX, modifiers etc did you bill.

If you didn't put on 2 separate lines with required modifier to show separate incisions, that could be one reason for this type of denial
 
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