Forum - Questions & Answers
Not A Covered Service
Hi We recently got a denial fro Amergiroup stating for CPT® 76856, 76830, 76831 AND 58340 stating as not a covered service for new York members when we called they stating Dx is invalid which we submitted can any body help us in fixing this issue. Braddy
re: Not A Covered Service
The submitted dx were 789.03, 218.1, 788.20, 608.9, v25.42. Please kindly advise.
Regards,
Braddy
re: Not A Covered Service
[The submitted dx were 789.03, 218.1, 788.20, 608.9, v25.42. Please kindly advise.
Regards,
Braddy]
re: Not A Covered Service
Your diagnosis codes are an issue. All codes, both diagnosis & CPT® indicate a female. 608.9 is unspecified disorder of male genital organs. You have a gender mismatch that will cause rejection by the payer.
re: Not A Covered Service
Hi dsteed,
First of all thank you very much for your help. I have some few clarification service where provided for both male the cpts are 76856 with dx 608.9 and female with dx code 625.9(UNSPECIFIED SYMPTOM ASSOCIATED WITH FEMALE GENITAL ORGANS) and 218.1(INTRAMURAL LEIOMYOMA OF UTERUS) and 218.2(SUBSEROUS LEIOMYOMA OF UTERUS) Please advise whether these dx are not covered we bill these dx based on gender.
Please Advise.
Braddy
re: Not A Covered Service
76856 should be covered for 625.9, 218.1 & 218.2 & for 608.9,
unless the payer has some specific coverage policy about the service.
Ensure they are not both reported on the same claim.
re: Not A Covered Service
Thank you desteed,
Likewise we have another issues with fideliscare since they denying the service for CPT® 75574 ST DENIED AS " Not a covered service or inclusive to another procedure" there is any substitute CPT® code.
Please Advise,
Braddy
re: Not A Covered Service
What were your diagnosis codes? Any other CPT® codes reported?
re: Not A Covered Service
We Billed CPT® 75574 dx 414.01 CPT® 71250 dx 414.01 CPT® Q9967 dx 414.01. Please kindly advise.
Braddy
re: Not A Covered Service
There are CCI edits for 71250 & 75574 as the greater procedure. Both may be allowed if medical necessity clearly allowed. Modifier 59 would be required.
More importantly, some payers will not reimburse for a CT scan & CT angiography on the same date. Rationale is that the lower level test might have given sufficient information without need for the higher level test. Higher level test may be allowed only if lower level test has been done previously & did not give sufficient information.
You really need to become familiar with the coverage policies of your payers.
re: Not A Covered Service
Hi dsteed, we have billed 76856 with Dx 608.9 for male, but insurance denied for The diagnosis is inconsistent with the patient's gender. Thank. Gopi
