Wiki G2212 not paying by BCBS

[allison.n.elliott14@gmail.com]

Hi! I am newer to family practice, and I cannot get BCBS (of Colorado) to pay G2212? The denials state, "diagnosis code and procedure code combination that is not reimbursable." and "Missing/incomplete/invalid other diagnosis." I can't find anything that shows the dx's we use to be invalid with this code. It is just an extension of the office visit. Does anyone get this code paid?

 

[sls314]

Hi! I am newer to family practice, and I cannot get BCBS (of Colorado) to pay G2212? The denials state, "diagnosis code and procedure code combination that is not reimbursable." and "Missing/incomplete/invalid other diagnosis." I can't find anything that shows the dx's we use to be invalid with this code. It is just an extension of the office visit. Does anyone get this code paid?

BCBS is difficult with the prolonged service codes (G2212 and 94417). You'd have to appeal with the office visit note, and it may still be denied if BCBS doesn't see justification for the prolonged services.

I code for radiation oncology, and I can occasionally get BCBS to pay a prolonged services CPT on our new patient visit. (My physicians spend a lot of time with the patients reviewing images, documentation, and pathology reports, and of course the patients & their families have a lot of questions.)

There used to be a list of acceptable diagnoses for prolonged services on the BCBS website. If I can find the link, I will post it.

Based on the difficulty I sometimes have getting BCBS to pay prolonged services even with metastatic cancer diagnoses, I'd guess it might be a tough sell in the family practice setting. However, I don't code family practice, so perhaps someone else can offer input on whether they ever get any of those claims paid.

 

[sls314]

Here's the prolonged services policy for Anthem BCBS applicable to Colorado:

https://www.anthem.com/docs/public/inline/C-08011.pdf

The document states that effective 10/1/23 the ICD-10 list I mentioned has been removed. (Except in Maine where there is a delayed implementation.)

The document also indicates that effective 5/19/23, G2212 is a bundled service. 94417 appears to still be allowed. (Bundled services policy for G2212: https://www.anthem.com/docs/public/inline/C-08003-ABCBS.pdf )

Hope this helps.

I hadn't looked for updates in awhile, so I guess I'm glad I went searching. We have Anthem in Ohio, so those documents are applicable to my physicians as well.