04/04/2022

Emblem Health Denial for CPT’s 11721 & 11055/11056

Emblem Health has been sending me chart requests before they will pay for 11721 and 11055/11056 starting in 2022. Is this a change in their policy ? Have other members been experiencing this?

Per the denial from Emblem Health, this claim was not coded correctly per the LCD guidelines for RFC:

• For both line items, the Q modifier is missing since a systemic condition is reported (I70.203)
• For CPT 11055, the diagnoses codes are not linked correctly- it should be coded with I70.203 as the primary diagnosis, followed by L84 only
• For CPT 11721, the diagnoses codes are not linked correctly- it should be coded with B35.1 as the primary diagnosis, followed by I70.203, then M79.675, then M79.674
• Modifier -59 was appended correctly with CPT 11721