Wiki 80053 - Medicare Denial

[june616]

Hello! The family practice I bill for does many of their labs in-house. For this particular claim, Medicare paid all labs except 80053 (CMP).

The dx codes are V77.99, V77.91 and 780.79

Denial reason: "Patient responsibility - These are non-covered services because this is routine exam or screening procedure done in conjunction with a routine exam."

This is my first time seeing this denial and am not sure how to fix it, if I can. Are there any issues with dx codes that were used? If not, I will submit the bill to the patient like the eob says to.

TIA!

 

[modliandvmh]

Medicare denial for Non Covered routine

Medicare will not cover ANY labs that are done as routine.... if the diagnosis is a V-code, they will be denied as patient responsibility, they won't cover these for screening purposes. Patients need to be told that labs done as "routine" (because they have no medical reason to have them performed) will be their responsibility.

 

[mitchellde]

Hello! The family practice I bill for does many of their labs in-house. For this particular claim, Medicare paid all labs except 80053 (CMP).

The dx codes are V77.99, V77.91 and 780.79

Denial reason: "Patient responsibility - These are non-covered services because this is routine exam or screening procedure done in conjunction with a routine exam."

This is my first time seeing this denial and am not sure how to fix it, if I can. Are there any issues with dx codes that were used? If not, I will submit the bill to the patient like the eob says to.

TIA!

Not all screenings are patient responsibility but many are. The problem I see here is that you use screening codes with a symptom code. You cannot do this as a test cannot be for screening and symptoms at the same time. Screening implies that the patient is a symptomatic and meets certain predetermined criteria for screening. If the patient is symptomatic and the provider is performing studies to determine the nature of the problem, then that is diagnostic and the symptom code is used.

 

[mitchellde]

Medicare will not cover ANY labs that are done as routine.... if the diagnosis is a V-code, they will be denied as patient responsibility, they won't cover these for screening purposes. Patients need to be told that labs done as "routine" (because they have no medical reason to have them performed) will be their responsibility.

"... if the diagnosis is a V-code, they will be denied as patient responsibility"
This is an inaccurate statement. V codes are not routinely denied as patient responsibility. Some are payer paid and some are patient responsibility. It is not the V code that is being denied but the medical necessity for the service provided was not met. Medical necessity might be a V code or it might not be.

 

[e.ladora@yahoo.com]

Medicare requires medical necessity codes

I work with labs as well, and I have done a lot of research on what can be billed. It can be that your problem is that your diagnosis code is not a medical necessity code for medicare. I have done a ton of research on medical necessity codes and I can tell you it is a pain. But- look into medical necessity codes for your cpt code on the medicare website and this will tell you if your diagnosis code is a medical care necessity code for your CPT code. Hope this helps.