06/14/2021

Fidelis Denials

Hi, Our Billing office director (CPC, CPCO, CPPM, CSFAC) sent me this: This is what my Fidelis rep sent me regarding the x-ray denials. I am told the following…. Regarding the diagnosis code denials, we received the following feedback: Fidelis and the NYSPMA collaborated on relaxation of authorization requirements and the expansion of podiatric eligibility. This extensive negotiation included code-by-code review of ICD10, CPT and HCPCS codes. In addition to executive leadership internal to Fidelis, the NYSPMA Board of Trustees and, CEO Arnie Tannen agreed to the terms. Please contact your society for further details. Here is the list of ICD-10 codes that have been denied for x-rays: L03.032 Cellulitis left toe L03.031 Cellulitis right toe L97.322 Ulcer left ankle, fat layer exposed L97.521 Ulcer toes and forefoot, left foot limited to skin breakdown L97.512 Ulcer toes and forefoot, right foot with fat layer exposed M76.822 Posterior tibial tendinitis, left M86.821 - right foot M77.52 Exostosis/capsulitis (other enthesopathy of left foot) M77.51 – right foot M72.2 Plantar fasciitis M79.671 Pain in right foot M79.672 – left foot M20.5X1 Hallux limitus right foot M20.5X2 – left foot M20.11 Hallux valgus right foot M20.12 – left foot M20.41 Hammertoe right foot M20.42 – left foot M21.6X1 Other acquired deformity right foot M21.6X2 – left foot M21.621 Bunionette right foot M21.622 – left foot M67.471 Gangion, right ankle and foot M67.472 – left foot M76.811 Anterior tibial syndrome, right foot M76.812 – left foot M77.41 Metatarsalgia, right foot M77.42 – left foot S93.692A Other sprain of left foot, initial encounter S90.211A Contusion of right great toe with damage to nail, initial encounter S92.325A Nondisplaced fracture of second metatarsal bone, left foot, initial encounter for closed fracture S92.524A Nondisplaced fracture of middle phalanx, right lesser toes, initial encounter for closed fracture S92.534A Nondisplaced fracture of distal phalanx of right lesser toes, initial encounter for closed fracture S99.221D Salter Harris Type II physeal fracture of phalanx of right foot, subsequent encounter for fracture with routine healing S92.811A Other fracture of right foot, initial encounter for closed fracture (MY APPEAL WAS PAID ON 5/21/21) T84.84XA Pain due to internal orthopedic prosthetic devices, implants and grafts, initial encounter This is what I have so far.

Members of the Association's Insurance Committee, along with the NYSPMA consultant Arnie Tannen, had a conference call with the medical directors of Fidelis this past week. There were several topics on the agenda including the recent spate of members with denied X-ray claims being told by Fidelis representatives that the current pre-auth policy requirement was initiated at the urging of the Association in concert with Fidelis medical directors. That is completely false. The Fidelis medical directors on the call apologized for these statements to our membership and have spoken internally to representatives who have been disseminating this false information. We anticipate it will stop. On the positive side, committee members are in active discussions with the medical directors to develop the correct logic in their claims system that will match radiological procedures with Dx codes so that the claims will process correctly. And it is anticipated that prior denied claims will pay as long as the procedure and the Dx match under the revised logic in the Fidelis system. Details of these changes will be provided to members in a subsequent newsletter. The change will not be immediate and we appreciate everyone's patience while these changes are worked through by Fidelis.