Wiki Help with a claim denial


Navarre, FL
Best answers
Patient with diabetes, hypertension and hypercholesterolemia came to the office and had labs reviewed and meds refilled for their multiple issues. The patient also had actinic keratosis removed at this visit. Claim was billed with 99214-25, 17000, 17003. Humana paid 17000 and 17003 but denied 99214 as bundled. I did appeal the office visit since issues other than 702.0 were addressed by the Dr. but my appeal was denied.

Is there anything else I can do or is it a lost cause? Should the Dr. have evuluated the pt for 702.0 and then brought him back for a different visit for the removal?

Thank you for your help, I look forward to learning about what to do in this situation :)
Was the decision to remove the keratosis made at this particular office visit? If so, you could add modifier 57 (decision for surgery). Let me know if this works.
In my past position I found that you need to go to the second level of appeal with Humana. You may also want to attach coding guidelines and CPT book documentation to your appeal, this seemed to help. Good Luck!