Common Denials in Podiatry
Below are the most common denial reasons and the best solutions to bill your claim.
Claim Denied, we reviewed ERA and Find That Claim was denied as “These are non-covered services because this is not deemed a ‘medical necessity by the payer. “So task created To coding team please review diagnosis and suggest further action.
This denial always occurs due to
- The wrong diagnosis code added by the coder
- Due to primary or secondary diagnosis issues
- Sometimes Medicare doesn’t cover some Dx codes.
Read the complete medical report carefully, find the exact Dx, and check the LCD to verify the Dx. When you add that appropriate Dx, your claim will be resolved.
If a claim is denied due to primary or secondary Dx, Check the LCD of the specified state in which that specialty lies. Some Diagnosis codes can not be billed alone primarily; always add a secondary Dx to fulfill its medical necessity.
If the claim is denied due to a coverage issue, and Dx provided in the medical notes doesn’t fulfill the medical necessity or medicare coverage plan. You need to add a GY modifier with that CPT, and your claim will get billed by insurance.
Claim Denied, “The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. These services are not covered when performed within the global period of another service.”
This type of denial is mainly related to the
- Missing modifier with E&M service performed on the same day with any podiatry procedure code
- Due to the global fee period issue.
To deal with such denials, always check the CCI edits between E&M and all other CPT codes of that DOS if there is any conflict between E&M and the procedure code. Always append modifier 25 to the Evaluation and Management code.
If the denial reason is only due to the global fee period, then check the postoperative period of all major surgical procedure codes.
Suppose there will be any procedure code done within the past 90 days. In that case, you have to replace the E&M CPT code with 99024 (Postoperative follow-up visit, typically included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason related to the original procedure).
Claim Denied as ”Missing/incomplete/invalid principal diagnosis”.
As the statement suggests, this denial occurs due to the
- The wrong or missing Diagnosis code was added by the coder
- The issue with primary or secondary Dx.
First, check the patient medical records of the patient of that service date to see the diagnosis made by the provider and then check the LCD(local determination coverage) of the denied CPT. Cross-match the diagnosis code in the LCD and choose the best Dx.
If the claim is denied due to the principal diagnosis code, i.e., primary Dx.
Check the patient medical records and add the primary medical necessity Dx before the secondary ICD-10 code.
Claim denied as “Services denied by the prior payers are not covered by this payer” procedure code 99213 is bundled with another procedure code.
The bundling issue always occurs due to missing modifiers.
Some CPTs are not included in each other and can not be billed in conjunction on the same date of service. There is always a CCI conflict between them.
- Bundling between two different procedures done on the same date of service
- Bundling between E&M and minor or major surgical procedure code.
When two different procedures are performed on the same date of service.
Suppose a doctor performs CPT 11721 and 11750 on the same day. So you can never bill it without using a modifier because these are two different procedures and have bundling issues (conflict) with each other.
You need to append modifier 59 with 11721 for the clear submission of the claim necessary for full reimbursement.
If an E&M service is performed with any podiatry CPT code on the same day.
Your claim will resolve only when you append modifier 25 with that E&M code. Because modifier 25 is used to separate the interventional and E&M codes.
Insurance verification denials:
- Due to payer coverage termination, a large proportion of claims for podiatry are rejected.
- Services provided are not being covered, or the maximum benefit for Podiatry services has already been supplied.
- If you have claims of patients who are frequent visitors to the facility, insurance details can change at any time. It is advised to regularly confirm insurance and coverage information by calling them.
- Verification entails determining a patient’s current coverage and insurance eligibility.
Prior Authorization Denial
Claim stuck in error and denied as ” The authorization selected has exceeded the number of units/visits allowed.
To get reimbursements, the payer must grant prior authorization; the claim must be submitted along with the authorization number.
Understanding these requirements is essential if you want to be reimbursed for your podiatry services because different payers have varied prior authorization policies and demand adherence to particular standards.
The number of units used for CPT codes multiplies the payment with each increase in number. So, the frequency of units should be according to the procedure or the amount of drug infused in the body as per medical records.
Can These CPTs Billed Together?: CPT 99213 with 11042, CPT 99213 with 11721, CPT 99214 with 11719, CPT 99214 with 11045 and 99215 with 11721
The answer is “Yes”. You can bill CPT 11042, 11721, 11719, and 11045 with any E&M Initial or established office visit codes e.g. 99214, 99213, 99204, 99215 etc.
First, when billing all Podiatry mentioned above procedure codes with any E&M service on the same service date, always append modifier 25 to that E&M code.
Secondly, your primary diagnosis code should never be the same for both E&M and podiatry procedure codes and also add any secondary diagnosis code if medically necessary and required.