Wiki Multiple Medicare Denials for Medical Necessity

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HeidiJo

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I apologize ahead of time for my ignorance, I am still new to coding/billing and have learned on the job through trial and error. I received 3 pages of denials from Medicare for " these are non-covered services because this is not deemed a "medical necessity" by the payer". But the codes used were 99203 (on 2 of patients), 99213 (on 8 patients) and 95972 (1 patient). All were billed with a minimum of 3 ICD-10 codes. I have checked the LCD rules and since 99213 and 99203 are office visits there aren't really any restrictions on what the diagnosis codes can be. I am at a loss as to what is incorrect on all of these.
 
HeidiJo said:
I apologize ahead of time for my ignorance, I am still new to coding/billing and have learned on the job through trial and error. I received 3 pages of denials from Medicare for " these are non-covered services because this is not deemed a "medical necessity" by the payer". But the codes used were 99203 (on 2 of patients), 99213 (on 8 patients) and 95972 (1 patient). All were billed with a minimum of 3 ICD-10 codes. I have checked the LCD rules and since 99213 and 99203 are office visits there aren't really any restrictions on what the diagnosis codes can be. I am at a loss as to what is incorrect on all of these.
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Can you give examples of some of the dx codes that were used?
 
99203 m41.20, m54.6, m54.5

99213 g89.4, m96.1, m25.579

62311 m54.16, m51.26, m48.06
 
Same issue

I am having the same issue with CO-50 denials. The denial codes are across the board from e/m to labs. Crossing my fingers there is an internal system error with Medicare. What contractor do you bill to?
 
I sure hope that is the problem, would make me feel a lot better!

I am in Oklahoma, not sure how to answer as to which contractor. My billing software program took care of all the "connections" with electronic billing so I am not sure what avenue my claims travel before they are paid. What is an example of a contractor name?
 
HeidiJo said:
I sure hope that is the problem, would make me feel a lot better!

I am in Oklahoma, not sure how to answer as to which contractor. My billing software program took care of all the "connections" with electronic billing so I am not sure what avenue my claims travel before they are paid. What is an example of a contractor name?
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I am in Oklahoma as well. We would use the same contractor, Novitas Solutions. I have spoken with a couple other group practices in Oklahoma as well. They are having the same issue. I will post if I find anything out.
 
Ha! Well Novitas was what I assumed I should answer but that seemed to simple! Thank you for your help!!
 
I am also in Oklahoma and also got a remit last week with about 40 different patients that all denied with co-50. I called Novitas on Friday and was told by the CSR that they were notified that morning of a system wide issue :( She said that there was no need to do anything on our part and that they should be reprocessed automatically. She said feel free to check status on the portal around the end of the week!!!

I must admit that I almost spit soda out of my nose when I got the remit!!

For the other commenters that in Oklahoma I would love to exchange email addresses! It's always nice to have some contacts in our state to holler at when something like this happens to see if it's just me or everyone!!
Btw my email is hollie_griffith@hotmail.com
 
hmgriffith said:
I am also in Oklahoma and also got a remit last week with about 40 different patients that all denied with co-50. I called Novitas on Friday and was told by the CSR that they were notified that morning of a system wide issue :( She said that there was no need to do anything on our part and that they should be reprocessed automatically. She said feel free to check status on the portal around the end of the week!!!

I must admit that I almost spit soda out of my nose when I got the remit!!

For the other commenters that in Oklahoma I would love to exchange email addresses! It's always nice to have some contacts in our state to holler at when something like this happens to see if it's just me or everyone!!
Btw my email is hollie_griffith@hotmail.com
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That is great news!!! What a relief. Thanks so much for the update!! I will shoot you an email :)
 
Denial 50 in Colorado

I have had at least 35 denials with the same E/M codes from dates of service from October to Current. It seems like they always come up with some issue not to pay us in the month of January!
 
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