03/22/2019

MCR Denial for 99203, 11055 and G0127

We received a claim denial for all 3 cpt codes. We don't understand the explanation on Medicare remittance advice. Please explain why Medicare denied our claim and what can we do? Do we resubmit the claim or appeal the claim?

In terms of the coding for the three procedures, there are multiple issues:

• The E&M code was denied as bundled to the other services on the claim because it was missing modifier 25; this needs to be added to the claim before it is resubmitted to the corrected insurance.
• The primary diagnosis for the E&M code needs to be changed- DX L84 is considered a routine condition and is not acceptable as a primary diagnosis. One of the hallux codes should be billed as primary since it is a more urgent medical need to be addressed over corns.
• Both routine foot care services were denied because they are not medically necessary. They are missing a systemic diagnosis listed on the routine foot care policy and a class findings modifier
• Routine foot care services could also be denied for a missing referring provider and date last seen from the referring provider in addition to the coding issue