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Old 08-16-2011, 11:58 AM
01085585 01085585 is offline
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Default 83036 denials

We are a family practice medical facility and we all of a SUDDEN received denials for 83036 which is checking the A1c. Has anyone else had a similar problem. The denials date back to 06,28.2011 that is when the denials started. Most of these have been 3 months or more from the last time 83036 was just to check the a1c. Any suggestions?
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Old 08-16-2011, 01:28 PM
Teresa Collins Teresa Collins is offline
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Are you appending modifier QW? Perhaps that could be an issue. How is the denial worded on the Medicare EOB?
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Old 08-16-2011, 02:58 PM
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we do append the QW modifier, we thought maybe that was the problem.
denial said
THE INFO SUBMITTED ON CLAIM FOR 83036 IS NOT SUFFICIENT FOR DETERMINING MEDICAL NECESSITY BY DIAGNOSIS OR FREQUENCY
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Old 08-16-2011, 07:01 PM
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Quote:
Originally Posted by 01085585 View Post
we do append the QW modifier, we thought maybe that was the problem.
denial said
THE INFO SUBMITTED ON CLAIM FOR 83036 IS NOT SUFFICIENT FOR DETERMINING MEDICAL NECESSITY BY DIAGNOSIS OR FREQUENCY
Just guessing, but it sounds like a new claim scrubbing edit that doesn't like your primary diagnosis. You should check the payor's website for updates to their medical policy bulletins, which should list what they consider 'covered' (ie, medically necessary) indications for an A1c.
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Old 08-16-2011, 07:07 PM
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Default Example...

Medicare NCD: http://ww.cms.hhs.gov/CoverageGenInf...l201107.pdf#10
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Old 08-17-2011, 07:21 AM
01085585 01085585 is offline
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Thank you for the info! I reviewed it and we are using 250.00 unless stated out of controlled we use 250.02... (unless type one etc...) Those appear to be covered dx, If I am reading the information you provided me correctly
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Old 08-17-2011, 07:29 AM
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Quote:
Originally Posted by 01085585 View Post
Thank you for the info! I reviewed it and we are using 250.00 unless stated out of controlled we use 250.02... (unless type one etc...) Those appear to be covered dx, If I am reading the information you provided me correctly
If that's the case, I'd challenge the denial. You're only billing 1 unit, right? How often? I'd definitely call the payor to see if you can figure out what triggered that denial code. It's probably a correctable issue. Good luck!
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Old 08-22-2011, 12:20 PM
lwallace42 lwallace42 is offline
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Medicare updates it's NCD policy manual twice a year. The last update was in July. It's free to download. This will be very helpful to you because it list the most common labs done and all the diagnosis that medicare( and most major payors) will accept to pay for those test. Hope this helps



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