Wiki Help, please - Medicare denials

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Pari9282

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Hello,
We have received a few denials for TCMs (99495 and 99496) with denial codes COB15 and PR167 from Humana. I checked everything, and nothing seemed to be wrong.
Also, seeing denials for office visits (99214 and 99215) with CO151 denial code. Again, I have checked everything; the Dx and the LOS are correct.
Please help me figure out what could be the issue.
 
Hi Pari9282:)
What are the dx codes linked to 99495 and 99496? CPT 99215 is used for pt must get hospitalized because very ill.
Here are list of common payer denials....
Denial PR167 means patient responsible not covering it.
Denial C0B15 means payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
Denial C0151 means service permitted more times than coverage allowed
Well hope this data helps you but can always check with payer
Lady T(y);)
 
Hello Lady T, thank you do much for explaining the denial codes.
So, what should the Dx code be for TCM visit, the one for which the pt was admitted (if it is still not completely resolved) or the dx at discharge or any other acute/chronic conditions the provider addresses during the TCM visit?
99215 is time based. So, not understanding what the issue could be.
But I will go back and look at the denials from the explanations you have mentioned in the reply, maybe it will make more sense now😊
Thanks again for helping me
 
Pari9282 said:
Hello,
We have received a few denials for TCMs (99495 and 99496) with denial codes COB15 and PR167 from Humana. I checked everything, and nothing seemed to be wrong.
Also, seeing denials for office visits (99214 and 99215) with CO151 denial code. Again, I have checked everything; the Dx and the LOS are correct.
Please help me figure out what could be the issue.
Click to expand...
If you haven't already done so, call the payer and ask them what other service they're bundling with or expect to see. There is no primary code requirement for 99495 and 99496 that I can see and it makes me wonder if they haven't received the discharge claim from the hospital at the time your claims were adjudicated.
 
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