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Wiki CPE denials...

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cmedina969800

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Albany, OR
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Hello,

I have a patient who came in for a CPE, but his insurance denied due to "max benefits paid for service." Patient called his insurance (PacificSource) and was told to have the office visit changed to an actual OV rather than the preventative service and then they will cover it. The chart note is clearly a "preventative" exam. I am not comfortable changing it to an actual OV.

Does anyone have any feedback they can provide? Is this even legal to do?

Thanks,

Christina, CPC-A
 
no you cannot change the code to an ov when it is indicated as an annual. did you use the V70.0 dx code? is it possible the patient did not wait the 365 days from the previous annual?
 
we get these all the time...people always call and want us to change it to an office visit or vice versa, but if they came in for a px there's nothing we can do. It's their responsibility to know whats covered BEFORE they come in, not after :)
 
Thank you for your input... :) Apparently his insurance allows a CPE every other year instead of yearly, so that's why he is wanting us to change it.

Christina
 
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