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jmercado

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Hello I am constantly getting medical records requested from Optum. They always deny for 'services do not support the level of service" when a 99204 is billed. Can someone please help me understand what constitutes a moderate complexity vs high and low?
 
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EACH PAYOR SEEMS TO PROCESS CLAIMS ACCORDING TO THEIR OWN INDIVIDUAL GUIDELINES. OPTUM WILL REQUIRE RECORDS FOR CLAIMS AND WILL NOT PROCESS IF THEY ARE NOT SENT IN A TIME,Y MANNER
 
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jmercado said:
Hello I am constantly getting medical records requested from Optum. They always deny for 'services do not support the level of service" when a 99204 is billed. Can someone please help me understand what constitutes a moderate complexity vs high and low?
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We see that denial and in our case it means it is not a new patient and established code should be used.
 
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andreasuemoore@hotmail.com said:
We see that denial and in our case it means it is not a new patient and established code should be used.
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With the claims that I review I show the patient is a new patient. In the even it is an established patient I do not have an issue it's just the the new patient codes that will deny for the level of service. That is why I ask what constitutes the level of service of moderate vs high and low?
 
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jmercado said:
Hello,

Yes referring for overall leveling of history, exam and MDM.
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So I think the reason why some of the posters (myself included) are a bit confused, is because of your wording of your question. When you say "Moderate Complexity", this usually explains the overall MDM, and does not explain History or Examination.

If you are looking for help to code the correct E/M level, then I highly recommend you study the CMS E/M guidelines first, and then look at the different E/M audit tools out there. There are plenty to choose from if you do a search. If your organization does not have an E/M audit tool, then I would suggest creating one, based on the guidelines and support available.

Let me give you a list of links that should guide you in the right direction:

CMS E/M guidelines
AAPC E/M audit tool
E/M University (Free section)

I would start studying these resources and then go from there.

As far as your denials go, they could be denied either based on the E/M level or patient status (New vs. Established). I would check both and reaudit them to see if you have grounds enough for an appeal.

Good luck!
 
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Pathos said:
So I think the reason why some of the posters (myself included) are a bit confused, is because of your wording of your question. When you say "Moderate Complexity", this usually explains the overall MDM, and does not explain History or Examination.

If you are looking for help to code the correct E/M level, then I highly recommend you study the CMS E/M guidelines first, and then look at the different E/M audit tools out there. There are plenty to choose from if you do a search. If your organization does not have an E/M audit tool, then I would suggest creating one, based on the guidelines and support available.

Let me give you a list of links that should guide you in the right direction:

CMS E/M guidelines
AAPC E/M audit tool
E/M University (Free section)

I would start studying these resources and then go from there.

As far as your denials go, they could be denied either based on the E/M level or patient status (New vs. Established). I would check both and reaudit them to see if you have grounds enough for an appeal.

Good luck!
Click to expand...


Thank you for the help.
 
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