G0009 denial

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Jacksonville, North Carolina
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Hello, everybody. I coded as below for pt. who has Humana medicare advantage and G0009 and 90670 got denied. Did I miss modifier? I hope someone can help me. Thank you very much in advance.

G0438-got paid
99497-33-got paid
99213-25-got paid
99397-got paid
G0009-got denied
90670-got denied
 

trarut

Expert
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Columbus, OH
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Crazy question but what diagnosis did you use on the pneumo codes? If it's anything other than Z23, that's likely the reason for your denial.
 

jhendrix08

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What denial codes and description is listed on the EOB? I'm actually really surprised that they paid for an office visit 99213 along with the AWV and a PE all in the same visit...
 
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Jacksonville, North Carolina
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What denial codes and description is listed on the EOB? I'm actually really surprised that they paid for an office visit 99213 along with the AWV and a PE all in the same visit...
Thank you for your time to reply on my post. denial/remarks are N115 N386 CO-96. I am a newbie to billing part, I appreciate for your help.
Yes, we usually get paid when medical necessary e/m service is done separately during the wellness visit.
 

NLCrew

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Hello, everybody. I coded as below for pt. who has Humana medicare advantage and G0009 and 90670 got denied. Did I miss modifier? I hope someone can help me. Thank you very much in advance.

G0438-got paid
99497-33-got paid
99213-25-got paid
99397-got paid
G0009-got denied
90670-got denied

If you are using UB04 form, you need to use the Condition Code for A6, revenue code 636 for Pneumonia/Influenza Vacc and revenue code 771 for administration of vaccine. Hope this helps!
 

trarut

Expert
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Columbus, OH
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We got paid with the same coding above from Medicare for other different pt. though.
Was it the same exact combination of CPT/HCPCS/ICD-10 + modifiers? And was it also a Humana MA plan that paid the other patient?

To be perfectly honest, I would simply call Humana and ask for more information about the denial and ask them to direct you to the exact policies they are basing the denials on. While I don't see any CCI edits for the codes you've billed, it would appear that the vaccine is caught up in the wellness visit or the preventative. (I'm still not sure how all three of those visits are being covered but I'm lucky to be in a specialty that doesn't deal with wellness and preventative visits.)

Hopefully someone else can provide a better answer on this one but sometimes, you just have to make a call when it comes to billing issues.
 
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353
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Hello, everybody. I coded as below for pt. who has Humana medicare advantage and G0009 and 90670 got denied. Did I miss modifier? I hope someone can help me. Thank you very much in advance.

G0438-got paid
99497-33-got paid
99213-25-got paid
99397-got paid
G0009-got denied
90670-got denied
Hi,

Perhaps 11 months have not passed since the patient received the other pneumococcal vaccine? This could cause a denial as the patient is eligible for the 13-valent vaccine one year (or 11 full months) after receiving the 23-valent vaccine. The remarks indicate that the charges were denied based on Medicare coverage policies so that is just a guess.

Cindy
 
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8
Location
Jacksonville, North Carolina
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Hi,

Perhaps 11 months have not passed since the patient received the other pneumococcal vaccine? This could cause a denial as the patient is eligible for the 13-valent vaccine one year (or 11 full months) after receiving the 23-valent vaccine. The remarks indicate that the charges were denied based on Medicare coverage policies so that is just a guess.

Cindy
Thank you very much for your post again. I will look into that. Have a nice day.
 
Messages
8
Location
Jacksonville, North Carolina
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0
Was it the same exact combination of CPT/HCPCS/ICD-10 + modifiers? And was it also a Humana MA plan that paid the other patient?

To be perfectly honest, I would simply call Humana and ask for more information about the denial and ask them to direct you to the exact policies they are basing the denials on. While I don't see any CCI edits for the codes you've billed, it would appear that the vaccine is caught up in the wellness visit or the preventative. (I'm still not sure how all three of those visits are being covered but I'm lucky to be in a specialty that doesn't deal with wellness and preventative visits.)

Hopefully someone else can provide a better answer on this one but sometimes, you just have to make a call when it comes to billing issues.
Thank you very much for your reply. Have a good day.
 
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