Wiki Medicare Denial New Patient Visit

[jhendrix08]

I've recently had some Medicare denials for new patient office visits and I need some help on figuring out why. One example: the dx's the physician linked to the CPT code were Z76.89 (Persons encountering health services in other specified circumstances, Z79.891 - Long term (current) use of opiate analgesic, and then a couple others relating to his health status, like blood pressure, etc.

The Reason code on the EOB is "PR-49 This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam."

The physician tends to use that Z76.89 Dx code as first listed for our new patient appointments. However, I did have another denial where that was not used so I'm unsure that the Dx code is the issue. The reason code of the denials I've received have all been that PR-49 code. Help! I appreciate it so much.

 

[daedolos]

Did the patient present with an illness or complaint? Query your provider to make sure documentation is clear.

Peace
@_*
If you are using Z codes as the primary code, you're bound to receive many denials.

 

[jhendrix08]

Many times, our Medicare patients come in to just "establish care" and may not necessarily have a specific complaint at the time. I had a feeling it was possibly the Z codes. Thanks for your feedback.

 

[CodingKing]

"get acquainted" visits are not payable under Medicare or any other type of insurance. CMS doesnt cover routine physicals either, needs to have a specific medical complaint or meet criteria for AWV to be billable.

 

[jhendrix08]

Thanks so much!