Wiki Modifier 24 ignored

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JesseL

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I've been getting denials from Healthfirst and one from BlueCross/BlueShield.

For the BC/BS claim I attempted to appeal this with with doctors notes but they upheld the denial.

Basically day one the doctor did 11100, 17110, and 17000.

On follow up (within 10 days) the patient followed up on the biopsy results which turned out to be skin cancer. Coordination of care for the skin cancer (refer to mohs surgeon) and full body exam was done. Billed 99214 with modifier 24, and for that BC/BS claim they upheld the denial as being part of the global for 17110 and 17000. I explained that the visit had nothing to do with 17110 and 17000.

Don't know what to do at this point.
 
How did you appeal?

Just a cover letter to fight the appeal?

Or did you send in notes for both visits... the initial and the follow-up visit, with the pertinent areas highlighted for the biopsy and the follow-up visit for the biopsy and to discuss results of the biopsy and to coordinate additional treatment.

The wording of chief complaint of the follow-up visit is important as is the wording in the cover letter/appeal is important.

CC: Patient is here to discuss biopsy results of lesion biopsied on XX/XX/XXXX and discuss treatment. Path shows BCC of the left cheek (or whatever the condiition and location).

Also the E/M visiit for the follow-up should be coded with the ICD-10 of the biopsy result (the new condition that has prompted the E/M)

Modifier 24 is correct, because it's an E/M unrelated to the 17000 and 17110. Again, your appeals cover letter should state this.

If you've done, this appeal AGAIN and take it up the chain of command for appeals. Worst case, contact the Medical Director.

It's a game and you just have to play it.
 
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Their response was to contact our provider rep. Who is extremely elusive and responds to you in a way that's as if she's reading off of a script. Basically it would be like talking to a wall. I'll try to appeal again but with Bluecross Blueshield, the whole company is like talking to a wall.
 
Yep.

The system is designed NOT to pay you and frustrate you to the point of giving up. Keep at 'em!
 
Is there anything I could say to intimidate them?

I know of one doctor that used a lawyer to threaten this same rep but her husband's a lawyer so free lawyer service right there... No way my boss would hire a lawyer for such a small claim.
 
Not really. Intimidation tactics don't work for the $10 an hour employee on the other end. As you said, they are following a script.

You have appeal rights. Use them.

Have your doctor call their Medical Director if their provider reps aren't providing customer service or are inappropriately denying claims.

If this is a repeated pattern of abuse or denails from the carrier, you can get the AAD involved too. Peggy Eiden at the AAD can intervene (some times).

Bully-Intimidation-Cartoon.png
 
Does your BCBS have a "second level" of appeals? If so, that would be your next step before taking bigger actions. When all else fails, file a complaint to your state's Insurance Commissioner's office.
 
I am betting that it is not the 17000 that the visit is part of it s the 11100. If the follow up visit is in relation to the biopsy result, and it is in the 10 day global of the 11100, then it is a global visit and it cannot e billed.
 
mitchellde said:
I am betting that it is not the 17000 that the visit is part of it s the 11100. If the follow up visit is in relation to the biopsy result, and it is in the 10 day global of the 11100, then it is a global visit and it cannot e billed.
Click to expand...

The 11100 has a 0 day global though.
 
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