03/27/2020

Part 1: Humana Bundling and Denying 11055 and 11720 and BCBS Not Recognizing SX modifier for 11720 and 11055

Can you please tell me what we need to do to fight these insurance companies? 1. Humana is not recognizing the SX modifier for 11720/1 with 11055/6/7 anymore. Bundling and denying the 1105- or the 1172- code. 2. Fidelis- not paying the 97597 debridement code or the 29740 strapping code as of sometime middle of last year. 3. BCBS is not recognizing the SX modifier for 11720/1 with 11055/6/7 anymore. They will not pay the paring of lesions with the debridement anymore. With Humana you can appeal with notes and I think they finally pay. But shouldn't these companies be going by Medicare guidelines? And how can they just stop paying for something they always paid for without any notice?

With Humana and Empire BC/BS, the only way to get additional payment when the Medicare advantage plans deny a component of routine foot care services is to appeal it. Medical documentation needs to be submitted because the plans have created edits at the time to deny payments unless the provider can prove that all of the services have been documented to reflect the coding submitted. While it is against the processing guidelines of Medicare that would only request documentation as part of a post payment audit, the Medicare advantage plans are exploring an opportunity to restrict payment to code pairs that are frequently paid in error due to insufficient documentation or improper coding.