Wiki Rejections

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heatherwinters

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Our billing department has given me some rejections to work on, I'm looking for some insight.

The first is for
11721, with dx 110.1, 703.8 I see two things printing on the remittance - one is PR167, the other is "*** ELIGIBLE INSURANCE PLAN NOT FOUND. NO PAYMENTS WILL BE APPLIED***


Next I have 11719, 703.8, 250.00 with CO45 and PR2
and again **eligible insurance plan......

Insight?
 
For the first one, the code (PR167) represents a noncovered service for this diagnosis and is patient responsibility (PR) per the CARC.

The second one looks to be an adjustment (CO) and also a patient coinsurance amount (PR2).

Do you have access to the Claim Adjustment Reason Codes and Remark Codes?
Here is the link if you need it:
http://www.wpc-edi.com/codes/claimadjustment

I hope this helps.
 
Abn

Thanks - can you tell me, when is an ABN required and not voluntary for foot care? What reject code would I see if an ABN was needed and we didnt obtain one?
 
For the first problem you need to contact the patient and find out what insurance the patient has and refile the claim. On the second problem is this commercial or Medicare insurance plan. If the plan is a commercial policy a ABN does not need to be signed. Personally I would contact the insurance and point out the patient is a diabetic as indicated by the second diagnosis. Some commercial plans will require you to submit a corrected claim with diabetes as primary diagnosis. Just as a heads up you can not have every patient being seen for routine foot care sign a ABN just is case you don't get paid. On the ABN you will need to state why the service will not be covered. If the office should get audited by Medicare you will get fined for abusing the ABN.
 
You need the Q modifier and the second one you need Q modifier & last time seen by treating physician for diabetes you will need to work with your software and clearinghouse to make sure ist appears on the right loop.
 
Medicare LCD

We have just started receiving rejections from Medicare and Medicare replacement plans. Our LCD says we need one of the Q modifiers depending on the classification (Q7, Q8 or Q9) or if we use a diabetic neuropathy diagnosis then we need to tell them the name of the doctor that saw the patient last for the DM and the date of that service (has to be within 6 months).
 
Additional Information if possible

My Doc is telling me that for 11721 I need to also use the TA-T9 modifiers in addition to the Q7, Q8 or Q9.

Super silly but.....how in the heck do you do this? I KNOW that you do NOT make a new line for each toe, but can you put multiple modifiers on the same procedure to show a span? I am SOOOOOOO confuzzled...:confused:
 
You do not use the T modifiers for code 11721 as it states 6 or more nails. It matters not which 6 more as you can only bill the code on one line item with one unit. Also T modifiers are anatomic and while you are allowed 4 modifiers per line item only one can be anatomic, so only one T modifier per line item on those codes you may use them on.
 
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