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C097 denial

  1. #1
    Default C097 denial
    Medical Coding Books
    This is my first time to deal with verifying denials so I am new to this ballgame. Is there anyone that can help me possibly understand what's wrong with this scenario.

    For same patient different dates of service:

    DOS 9-9-10 Denied CPT code 15738-RT & 35860.
    Denial code reason C097- global with DOS 7-29-10 & 8-19-10 for CPT codes 35661 & 36830

    DOS 9-17-10 CPT codes 49324,36561, and 11043
    Denail code reason C097- global with DOS 7-29-10 & 8-19-10 for CPT codes 35661 & 36830

    Do I need to add certain modifiers to the denied CPT codes for them to be paid? I am totally lost here.

  2. Default
    Quote Originally Posted by samanthat View Post
    This is my first time to deal with verifying denials so I am new to this ballgame. Is there anyone that can help me possibly understand what's wrong with this scenario.

    For same patient different dates of service:

    DOS 9-9-10 Denied CPT code 15738-RT & 35860.
    Denial code reason C097- global with DOS 7-29-10 & 8-19-10 for CPT codes 35661 & 36830

    DOS 9-17-10 CPT codes 49324,36561, and 11043
    Denail code reason C097- global with DOS 7-29-10 & 8-19-10 for CPT codes 35661 & 36830

    Do I need to add certain modifiers to the denied CPT codes for them to be paid? I am totally lost here.
    So on 07/29/10 & 08/19/10 did you bill out 35661 & 36830? Because those CPT's have a 90 day Global period attached, and anything done within that 90 days that is related to the initial procedures will be denied unless taken back to the OR....and then a modifier would need to be attached. Either -78 for complication related to the initial procedure, or -79 unrelated to the initial procedure. Watch those Global Days....and you were lucky that the insurance carrier was nice enough to give you the dates of initial procedures...most carriers don't give any explanation much at all.
    Jenna

  3. #3
    Default
    If your payer is Medicare (our MAC is Trailblazer Health), be prepared to possibly get another denial for the same reason after you've corrected/refiled your claim to add the modifier. I've found that if I've corrected a claim & refiled with the 24, 78 or 79 modifiers...I get another denial for the same original thing. At that point all I've known to do is get records & send in as a redetermination request....& then will get payment.

  4. #4
    Default
    Thank you for your responses. The help was greatly appreaciated.

    Now I have one more of these and I will be able to finish this project.

    Another C097 edit for codes 32215,31622, and 32500- These 3 codes were billed together and I'm sure that one or two of them is an inpatient procedure only but I'm not sure which modifier I need to add the 59 modifier for all of them to go through. The edit says the 32215 and 31622 are bundling with the 32500. Any suggestions.

    Thanks,
    Samantha

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