02/21/2019

Today’s Options Denial for CPT 97597

Today's Options has denied payment on code 97597 when it was billed with codes 11056 & 11721. 97597 was billed as primary code and no modifier, 11056 & 11721 was billed as 2nd and 3rd codes both with modifier -xs. They are saying code 97597 is bundled with 11056. I have appealed this, but they continue to deny. Is there a way to bill all 3 codes at the same time and have them all paid?

Based on the details listed in the inquiry, the claim was coded appropriately showing the wound debridement is a separate service from the removal of corns and calluses.

If an insurance denies the two services (which is likely based on the nature of the service and CCI edits for the two procedures), notes would need to be submitted to show that the sites for the two procedures do not overlap and are in separate locations.

If the insurance upheld the denial even after supporting documentation was submitted, the best recourse would be to speak to someone at the insurance (with a clinical background, not customer service) and find out what information was lacking in the notes that made the denial stand as-is.

Those points would help see if the additional information can be added in an amended note for reconsideration to the Medicare Advantage plan, and prepare for future instances where a payer may deny the services for bundling and the documentation will be adequate to justify the billing of the different foot care procedures.