Wiki Medical Biller

[leortiz]

I received a denial for my entire claim stating that claims for procedure code 99214, 94640 & J7613 violate the claims edit for the Medicare Advantage plan. Diagnosis codes used were j45909 and R062. I'm attempting to write an appeal, but wanted to see if anyone else is having a problem getting paid by Medicare advantage plans for these codes.

Thank you,
Linda

 

[suzyqbiker]

General Practice Biller, CPB, 20+ years experience

It's the combination of the E&M and the 94640 - several Medicare Advantage Plans in MI will not pay 94640 without a mod 25 on the E&M, even though, we know this is not correct.

 

[mitchellde]

Its your diagnosis codes. J45.909 cannot be used with R06.2 you need to look at the excludes 1 edit. This will make the entire claim deny

 

[Pathos]

Its your diagnosis codes. J45.909 cannot be used with R06.2 you need to look at the excludes 1 edit. This will make the entire claim deny

I agree with Deb; if you look under J45 in the ICD-10 book, you will see:

Asthma

INCLUDES.....

[EXCLUDES]
J69.8
J82
J60
[B][SIZE=3]R06.2[/SIZE][/B]
J67.8

And as Suzy said, if you are billing a procedure with an E/M, you will need to have a Modifier 25. That is, if the procedure is medically necessary.