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Thread: Insurance company changing a code?

  1. #1
    Join Date
    Apr 2007
    Durham, NC

    Question Insurance company changing a code?

    AAPC: Back to School
    United Healthcare recently requested medical records on a series of patients. These pts were all billed with 92xxx codes with medical diagnoses as primary. Upon review of the medical records, UHC reversed the 92xxx codes we had billed with and repaid using 99xxx codes! Has anyone had UHC do this to them before? Of course the allowed amount was less, so they recouped the difference. The weirdest part to me is that they changed the codes froma code with looser documentation requirements (92014) to one with stricter requirements (99214). I was under the impression that if a visit qualified for a 99214, it most likely qualified for a 92014. These are annual eye exams on older patients with a series of medical problems, so the exams were pretty comprehensive. A refraction was also billed with routine dx code on each patient, as well as retinal photos where appropriate.

    I could make sense of it if they simply denied the code combo, if for example they had certain rules about 92 codes requiring a routine primary diagnosis, but that's not what they did.

    Has anyone had this experience with UHC or another payer?

    Thanks in advance,

    Last edited by annawade13; 11-21-2011 at 11:59 AM. Reason: typos

  2. #2
    Join Date
    Apr 2007
    Fullerton/Buena Park, CA


    I've had it happen when the insurance didn't pay even w/ a medical Diagnosis. It's because some insurance companies have labeled 92004, 92014, 92002, 92012 as vision codes (associated to routine vision exams) only and not medical. We did have to change the vision codes to e/m codes inorder to get paid.

    I don't remember if an insurance ever changed a code on us before. Did you contact UHC to find out why they did this?
    Jennifer DeWitte, CPC, CPC-P, CPB
    Newport Center Surgical
    Coding & Billing Department

  3. #3
    Join Date
    Apr 2007
    Durham, NC


    Thanks for the response. Yes, I've had some insurances dislike the 92xxx codes with medical, but UHC hasn't been one of them. Plus, they only did it for 6 charts, and left the rest as is. Looks like it was a one-time thing, but I'll call them to see what's up. It was alarming to me that they would just take over the coding like that!

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