01/14/2022

BCBS Denial for CPT 10021

For services on 12-8-21, I received a denial on CPT 10021, which was performed in my office for a soft tissue mass, on the foot, and BCBS gave denial reason "payment denied when performed/billed by this type of provider. This provider type/ provider specialty may not bill this service." This WAS NOT for a ganglion, so the aspiration code would not be appropriate. I performed the dry aspiration technique and sent out the specimen for evaluation. When we called BCBS, we were told the same thing. That CPT 10021, was not billable by a podiatrist. Is this a problem that others have had? Is there a recourse? Is this an known/active issue NYSPMA is pursuing with BCBS or other insurers? I am willing to submit documentation for their appeal process, but is there anything else that should be done? I'm not very hopeful on the appeal process, based on their denial reason.

This issue with CPT 10021 is not an active issue known to the NYSPMA. Some policies (whether it is Blue Cross or another insurer) specifically carve out certain procedures; there is not much recourse that can be made to appeal the denial from the insurance. Commercial payers like Blue Cross can mandate that if this service is medically necessary for the patient, that it must be done by a particular type of specialist, or by a participating ancillary provider in order for it to be reimbursed.

Even if it is medically necessary for a podiatrist to perform the FNA (with or without imaging guidance), if a provider specialty restriction is in place that may be specific to the patient’s policy or all plans, the service should not be performed in the future to avoid potential loss of revenue. An appeal to justify the medical necessity can be done to demonstrate the need to have the biopsy paid on a one-time basis.