Hi We recently got a denial fro Amergiroup stating for CPT® 76856, 76830, 76831 AND 58340 stating as not a covered service for new York members when we called they stating Dx is invalid which we submitted can any body help us in fixing this issue. Braddy
Your diagnosis codes are an issue. All codes, both diagnosis & CPT® indicate a female. 608.9 is unspecified disorder of male genital organs. You have a gender mismatch that will cause rejection by the payer.
First of all thank you very much for your help. I have some few clarification service where provided for both male the cpts are 76856 with dx 608.9 and female with dx code 625.9(UNSPECIFIED SYMPTOM ASSOCIATED WITH FEMALE GENITAL ORGANS) and 218.1(INTRAMURAL LEIOMYOMA OF UTERUS) and 218.2(SUBSEROUS LEIOMYOMA OF UTERUS) Please advise whether these dx are not covered we bill these dx based on gender.
Thank you desteed,
Likewise we have another issues with fideliscare since they denying the service for CPT® 75574 ST DENIED AS " Not a covered service or inclusive to another procedure" there is any substitute CPT® code.
There are CCI edits for 71250 & 75574 as the greater procedure. Both may be allowed if medical necessity clearly allowed. Modifier 59 would be required.
More importantly, some payers will not reimburse for a CT scan & CT angiography on the same date. Rationale is that the lower level test might have given sufficient information without need for the higher level test. Higher level test may be allowed only if lower level test has been done previously & did not give sufficient information.
You really need to become familiar with the coverage policies of your payers.