whitey86
New
I code for an ASC in Louisiana. Hoping someone could point me in the right direction or if anyone is having the same issue. I'm helping out my denials specialist on this procedure. All of our Medicare Advantage plans are denying 0275T. The one insurance in particular we are the most concerned about is Humana Gold. They are denying all the claims with no full detailed reason as to why. They say they follow CMS guidelines. Once denial is received, we have to appeal to Medicare and once reply is received that the code is payable this information is attached to our appeal to Humana and they finally pay. Problem is, is that it has to be done for every single claim that we bill out. The procedure is done quite often and we have no other problems with the other payors.
We follow LCD Article #A56902 and claims are coded like:
0275T
modifier Q0
dx: M48.062, Z00.6
Clinical trial #03072927
D4
Condition code 30
Claims are submitted by paper with medical records and authorizations attached. Please tell me why Humana denies this the first time and we have to go through Medicare and then submit an appeal to Humana every single time? Is this something I am missing in a coding perspective or is there something else that needs to be submitted with records on the first time? Is there a note that needs to be added to the claim form? Everything above is coded per guidelines.
Your help is truly appreciated.
We follow LCD Article #A56902 and claims are coded like:
0275T
modifier Q0
dx: M48.062, Z00.6
Clinical trial #03072927
D4
Condition code 30
Claims are submitted by paper with medical records and authorizations attached. Please tell me why Humana denies this the first time and we have to go through Medicare and then submit an appeal to Humana every single time? Is this something I am missing in a coding perspective or is there something else that needs to be submitted with records on the first time? Is there a note that needs to be added to the claim form? Everything above is coded per guidelines.
Your help is truly appreciated.
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