11/23/2022
Fidelis Denials-"Patient does not meet coverage guidelines" for CPT 11721
I have received several denials from Fidelis stating "Patient does not meet coverage guidelines" (Y52). One representative said it was a denial error and sent back for reprocessing. Another says it is denied for not having the appropriate modifier and an approved diagnosis. The diagnosis codes are: E11.9, M21.611 -99213 M25 E 11.9, B.35.1, M79.674 and M79.675-11721 (no modifier) The Fidelis plans involved are both Medicaid and Dual Advantage.
Both procedure codes were denied by Fidelis Care for the following reasons:
- The office visit has a diabetic diagnosis that is not covered under the Medicare advantage plan. Diabetic diagnosis codes can be billed but must be related to mononeuropathy, polyneuropathy, autonomic polyneuropathy, peripheral angiopathy, or other neurological complications.
- The nail debridement was also denied for an invalid diabetic diagnosis (see above), in addition to a missing class findings modifier
In order for diabetic foot care to be covered by the Medicare advantage plans, they need to be billed with a covered diagnosis (see below). If one of the following conditions are not billed on the claim, diabetic foot care will not be covered by the plan.
|
Code |
Description |
|
E08.41* |
Diabetes mellitus due to underlying condition with diabetic mononeuropathy |
|
E08.42* |
Diabetes mellitus due to underlying condition with diabetic polyneuropathy |
|
E08.43* |
Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy |
|
E08.44* |
Diabetes mellitus due to underlying condition with diabetic amyotrophy |
|
E08.49* |
Diabetes mellitus due to underlying condition with other diabetic neurological complication |
|
E08.51* |
Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene |
|
E08.52* |
Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene |
|
E08.59* |
Diabetes mellitus due to underlying condition with other circulatory complications |
|
E08.610* |
Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy |
|
E09.42* |
Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy |
|
E09.49* |
Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication |
|
E09.51* |
Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene |
|
E09.52* |
Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene |
|
E09.59* |
Drug or chemical induced diabetes mellitus with other circulatory complications |
|
E09.610* |
Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy |
|
E10.41* |
Type 1 diabetes mellitus with diabetic mononeuropathy |
|
E10.42* |
Type 1 diabetes mellitus with diabetic polyneuropathy |
|
E10.43* |
Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy |
|
E10.44* |
Type 1 diabetes mellitus with diabetic amyotrophy |
|
E10.49* |
Type 1 diabetes mellitus with other diabetic neurological complication |
|
E10.51* |
Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
|
E10.52* |
Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene |
|
E10.59* |
Type 1 diabetes mellitus with other circulatory complications |
|
E10.610* |
Type 1 diabetes mellitus with diabetic neuropathic arthropathy |
|
E11.41* |
Type 2 diabetes mellitus with diabetic mononeuropathy |
|
E11.42* |
Type 2 diabetes mellitus with diabetic polyneuropathy |
|
E11.43* |
Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy |
|
E11.44* |
Type 2 diabetes mellitus with diabetic amyotrophy |
|
E11.49* |
Type 2 diabetes mellitus with other diabetic neurological complication |
|
E11.51* |
Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
|
E11.52* |
Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene |
|
E11.59* |
Type 2 diabetes mellitus with other circulatory complications |
|
E11.610* |
Type 2 diabetes mellitus with diabetic neuropathic arthropathy |
|
E13.42* |
Other specified diabetes mellitus with diabetic polyneuropathy |
|
E13.49* |
Other specified diabetes mellitus with other diabetic neurological complication |
|
E13.51* |
Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene |
|
E13.52* |
Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene |
|
E13.59* |
Other specified diabetes mellitus with other circulatory complications |
|
E13.610* |
Other specified diabetes mellitus with diabetic neuropathic arthropathy |