Wiki Inconsistent with DX denial

[jijikaren]

Please I need help, has any body come across this type of denial and what did you do for claim to be paid.
billed as following:
99211 dx code V04.0
90460 V04.0
90713 V04.0
all line item paid except the 90460 denied for procedure or service submitted for payment remains inconsistent with the member's diagnosis.
Appeal sent but denied.

 

[mitchellde]

You cannot code a 99211 for an injection. The code 90460 includes counseling by a physician or other qualified person as a part of the code and there is no other service being rendered. You can code the 90460 and the 90713

 

[jijikaren]

Debra, I am just working on old accts for this provider. I told him office visit cannot be coded with only vaccines shots for this case. but he stated some Insurance do pays and wants me to appeal it.

 

[eadun2000]

Debra, I am just working on old accts for this provider. I told him office visit cannot be coded with only vaccines shots for this case. but he stated some Insurance do pays and wants me to appeal it.

If the patient comes in ONLY for vaccines and ONLY vaccines were done, then you CANNOT bill for a 99211. Billing 99211 for payment when nothing else was done to support that E&M is FRAUD.

 

[lnaschke]

Who is the payer?

I have found that Tricare and Cigna both have systemic issues with the implementation of this code. Have you called the payer to ask why it is denying for this reason? Usually if you ask to have the claim reconsidered, it will be reprocessed correctly.