04/16/2021
Fidelis Denials for E&M billed with RFC
Fidelis; billed 99212 with 11720 - denied 99212" as the benefit for this service is included in the payment/allowance for another service that has already been adjudicated". Was only paid for 11720- $17.23
These types of denials are becoming increasingly common with managed care plans with routine foot care. Even with distinct diagnosis codes for an E&M and RFC procedure, and proper modifier use, insurances are paying for the routine foot care charges but denying the office visit as bundled with routine foot care. While Medicare would pay for both procedures, plans like Aetna, Blue Cross, United Healthcare, Fidelis and other advantage plans are denying charges only paying for one of the two procedures (whether billing 11055-11057 or 11719-11721). The only recourse would be to appeal the denial from Fidelis Care under the basis that the coding submitted substantiate separate payment. Notes should be submitted from the DOS along with the appropriate appeal form to have the claim reconsidered with supporting documentation (the appeal form is attached).