Wiki Excludes1 Denials

[eharloff]

So a patient of ours came in for her CPE and was also due for her depo injection.
We used 99395-25 and 96372
Dx code for 99395, Z00.00
Dx code for 96372 Z30.42.
The insurance denied it stating they cannot be billed together, even though the patient received her depo injection the same day as her CPE. How is it that we now have to write-off the fee of the depo injection when she was due for the injection?

 

[thomas7331]

Why would you have to write this off? Writing something off is a business decision that a practice makes when it's been determined that the cost of pursuing payment exceeds the value of the expected payment. Payers can't force you to write something off if you don't choose to do so.

In this case, if both of these services are covered benefits under the patient's plan, then they should be paid. The insurance company has made an error here and you should take whatever steps are available to you to get them to correct it. As per the ICD-10 guidelines, Section I.A.12.a, "An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other." These are clearly two unrelated services, as you've said, so an exception would apply, and the denial is incorrect. If they refuse to override the denial, then I would ask them to give you guidance on how they expect you to code and bill their claims in this situation.

Then again, if it's an isolated case and not a recurring problem, you might decide it's not worth the time to fight. After all, 96372 is not a high dollar service and your practice's resources may be put to more productive use elsewhere, in which case writing it off might be the better option.