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Becca2023

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These are the denial reasons from BCBS KC and BCBS OOS and all are for CPT 88305. There are 3 different denial reasons depending on where you look. All the claims are from July.

This denial is what is on the BCBS website for claims, "Procedure is inappropriate for patient age"

This denial is on the Explanation of payment that is attached to the account. "Adjustment Reason Codes6 :The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."

This denial is on the scanned Remittance Advice EOB "Line 1 -Explanation of Prov Write Off: PDC This charge has been processed based upon the provider's participation status and your contract terms."

Is anyone else experiencing these type of rejections?
 
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Becca2023 said:
These are the denial reasons from BCBS KC and BCBS OOS and all are for CPT 88305. There are 3 different denial reasons depending on where you look. All the claims are from July.

This denial is what is on the BCBS website for claims, "Procedure is inappropriate for patient age"

This denial is on the Explanation of payment that is attached to the account. "Adjustment Reason Codes6 :The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."

This denial is on the scanned Remittance Advice EOB "Line 1 -Explanation of Prov Write Off: PDC This charge has been processed based upon the provider's participation status and your contract terms."

Is anyone else experiencing these type of rejections?
Click to expand...
Yes, coworker called anthem and of course they said they will send back for review.
 
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We are getting that denial when billing with 45380 (colonoscopy with bx). We are billing with revenue code 310 - Laboratory - pathological - which I think is incorrect. I think it should be 314 - Bx. BCBS rep stated it was a revenue code issue but no specifics. Claim was processed correctly after being sent back. Coder said it was correct, but again, I think otherwise. Curious what revenue code is being used with 88305 on your denials.
 
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Becca2023 said:
These are the denial reasons from BCBS KC and BCBS OOS and all are for CPT 88305. There are 3 different denial reasons depending on where you look. All the claims are from July.

This denial is what is on the BCBS website for claims, "Procedure is inappropriate for patient age"

This denial is on the Explanation of payment that is attached to the account. "Adjustment Reason Codes6 :The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."

This denial is on the scanned Remittance Advice EOB "Line 1 -Explanation of Prov Write Off: PDC This charge has been processed based upon the provider's participation status and your contract terms."

Is anyone else experiencing these type of rejections?
Click to expand...
I would need details here. It almost has to do with patient's age with first reason. Was this an infant or pediatric patient here requiring an alternative diagnosis code?
By the time you receive any response from someone else you will you be potentially timely from BCBC (even if no one else is advocating for you here) for anything here.
Someone from your facility needs to call BCBS and find out the denial reason here. I wouldn't advise a biller CLEARLY because a coder holds more ground from ALL the calls I have ever made.
The reason I state that is because once they BCBS has a coder on the line and all the reasons why, those reasons to talk to the insurance company dissipate
I have been crabby more than once dealing with insurance companies. BCBS isn't my least favorite, but it was a BUTT HEAD. You get an actual coder to discuss those denials (not someone random, but someone that really understands coding assignment and discusses), that stuff probably doesn't happen anymore here. Ouch! It was there "back in the day". Just so you know.
 
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