Wiki 99205 and 99417 diagnosis code denial

[lfontanez]

Hi everyone. Has anyone ever received a denial for 99417 due to dx codes used? We used the same for the both 99205 and 99417. The 99205 was paid as allowed but the 99417 was denied as "not eligible for reimbursement with reported diagnosis."

 

[lgardner]

Hi everyone. Has anyone ever received a denial for 99417 due to dx codes used? We used the same for the both 99205 and 99417. The 99205 was paid as allowed but the 99417 was denied as "not eligible for reimbursement with reported diagnosis."

what dx codes were used?

was 'time spent' documented?

 

[amyjph]

Same question. What was the diagnosis?
It has to be at least 15 minutes beyond the max for 99205 and documented correctly.
I have also seen a payer assign the incorrect reason for a denial before.

 

[lfontanez]

Codes used were: Z14.1, Z86.19 and R77.1
I'm a little perplexed since BCBS paid the full allowed for 99205.

 

[jkyles]

Codes used were: Z14.1, Z86.19 and R77.1
I'm a little perplexed since BCBS paid the full allowed for 99205.

If Anthem is the payer, they have diagnosis code edits for prolonged service codes. A link to the list is at the end of their policy: https://www.anthem.com/docs/public/inline/C-08011.pdf

 

[amyjph]

Codes used were: Z14.1, Z86.19 and R77.1
I'm a little perplexed since BCBS paid the full allowed for 99205.

Yes, those diagnoses are not going to cut it for the prolonged.

 

[lfontanez]

Yes, those diagnoses are not going to cut it for the prolonged.

Do you have a suggestion? Because this was an immunology work-up, so those codes would follow under what was diagnosed.

 

[amyjph]

Do you have a suggestion? Because this was an immunology work-up, so those codes would follow under what was diagnosed.

You would have to refer to the link provided above. The documentation would have to support the diagnoses.

 

[lfontanez]

Yeah, that's the problem. We have supporting documentation but they are not asking for that. All I'm getting from my local BCBS rep and the plan rep, is what I stated above. ¯\_(ツ)_/¯

 

[amyjph]

Yeah, that's the problem. We have supporting documentation but they are not asking for that. All I'm getting from my local BCBS rep and the plan rep, is what I stated above. ¯\_(ツ)_/¯

They don't have to ask for it if the diagnosis on the claim does not meet the criteria in the list. It has nothing to do with the fact that they allowed 99205. It is spelled out in that policy document link:
Except as described in this policy, prolonged services are not eligible for separate reimbursement. Prolonged Services ICD-10 List: Prolonged services codes 99354, 99355, 99417, and G2212 will be eligible for reimbursement when reported with one or more of the following: https://www.anthem.com/docs/inline/PS_ICD-10_Codes_21.pdf

If it does not fall in that list, they are not going to pay it.

 

[lisa30052@gmail.com]

The BCBS policy that was given is referring to diagnosis exemptions for the state of Maine only.

Hi everyone. Has anyone ever received a denial for 99417 due to dx codes used? We used the same for the both 99205 and 99417. The 99205 was paid as allowed but the 99417 was denied as "not eligible for reimbursement with reported diagnosis."

Can I ask how you resolved this? We have received the same rejection.

 

[CBLENNIE]

The policy states at the top of page 2 the following:

So, it seems as though there are very few elements of an encounter that Anthem would count towards 99417 and that they would consider reimbursable.

Also, there is a statement in the policy that indicates the initial determination of reimbursement is based on claims-data analysis. So, they likely have an algorithm that they use to determine based on the DX codes billed whether the 99417 is reimbursable when the claim is initially processed since the exception list applies to the state of Maine only. You may have to submit an appeal with supporting documentation to try and get them to reimburse you for 99417, although the bar seems high to meet the criteria for separate reimbursement based on the information, I pasted in this comment from their policy of all the things they consider bundled into the E&M and would not be counted towards the prolonged time services.

 

[natashalage]

Hello everybody and Merry Christmas, Happy holidays to all of you. I apologize if I’m wrong and I don’t have CPT book with me, but may be the reason for the denial is that a wrong CPT code was used? I believe for Medi-cal, Medicaid the prolonged E/M is 99417 but for Medicare and all other insurances, it should be G2212. (Again, I’m sorry, maybe I had too much eggnog today) I don’t have CPT book with me but I know there are two different CPT codes for prolonged EM in office outpatient setting.