Wiki Denials for med nec

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h.henry@src

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CPC-A newbie here...currently employed as an intern coder/biller and am struggling to resolve denials for medical necessity. I have one insurance plan in particular that I am working for these denials on CPT 87905 and have searched the provider resources on their portal and called the payer with no results.
Advice please as to where I can find general tips/information on working claims for medical necessity and what exactly the payer is looking for? Or where to focus my searching on the payer site? Any guidance is appreciated as I learn to navigate life as a coder/biller 🙂
 
h.henry@src said:
CPC-A newbie here...currently employed as an intern coder/biller and am struggling to resolve denials for medical necessity. I have one insurance plan in particular that I am working for these denials on CPT 87905 and have searched the provider resources on their portal and called the payer with no results.
Advice please as to where I can find general tips/information on working claims for medical necessity and what exactly the payer is looking for? Or where to focus my searching on the payer site? Any guidance is appreciated as I learn to navigate life as a coder/biller 🙂
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What diagnosis code are you billing with it?

Often when a lab code gets denied for medical necessity, it means that you're billing a diagnosis code that doesn't fit the payor's definition of medical necessity.

Also, which payor? Perhaps someone can help lead you to that provider's clinical policy for the drug.
 
Hello There H.Henry :)
The CPT lab code 87905 is looking for some type of infection or bacteria from vaginal or skin or unknown which is why provider order this lab But you must read the medical record for dx codes given for the treatment of the day. Or query provider why he or she ordered this lab. Per the editing system we use which links CPT lab codes with a list of dx codes popped up. I shall list the dx code associated with CPT 87905 which are dx blocks of B96, A59, L29, F19, Z11.8, Z11.2 and Z86.19 . I hope this data helps you

Lady T(y)
 
sls314 said:
Here's an example of diagnosis codes that fit one payor's definition of medical necessity for 87905. See Table 2 on page 5 of this PDF.

This is just an example - it doesn't mean that it is the exact list for your payor, but you should be able to find a similar document for that payor that spells it out like this:

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Thank you for kind and prompt reply and providing the example! I am hopeful I may soon find something similar on the Illinois Meridian portal. I will continue the search for their policy as I would like to add further justification to my write-off for medical necessity.
 
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TThivierge said:
Hello There H.Henry :)
The CPT lab code 87905 is looking for some type of infection or bacteria from vaginal or skin or unknown which is why provider order this lab But you must read the medical record for dx codes given for the treatment of the day. Or query provider why he or she ordered this lab. Per the editing system we use which links CPT lab codes with a list of dx codes popped up. I shall list the dx code associated with CPT 87905 which are dx blocks of B96, A59, L29, F19, Z11.8, Z11.2 and Z86.19 . I hope this data helps you

Lady T(y)
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Thank you! I have no additional codes that can be added to the claim after further search and query to provider, but am still hoping to find the specific policy for Illinois Meridian to have further justification because I must write-off. There is much to learn when navigating the payor sites...I sure hope I become more efficient!
 
h.henry@src said:
Thank you for kind and prompt reply and providing the example! I am hopeful I may soon find something similar on the Illinois Meridian portal. I will continue the search for their policy as I would like to add further justification to my write-off for medical necessity.
Click to expand...


Coincidentally, the link I provided above is for Centene, so it actually does apply to you. (Centene owns Meridian Health Plan.)

Here's the same document linked on the Meridian Illinois website:
https://www.ilmeridian.com/content/dam/centene/meridian/il/policies/1138/Testing for Select Genitourinary Conditions CP.MP.97 (1).pdf
 
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