12/15/2022

Fidelis Denials for 11721 and Post-Op Periods for CPT 28820 and 28825

We are having 2 major issues with Fidelis. 1- regarding 11720 and 11721 you posted issue with Fidelis Denials-"Patient does not meet coverage guidelines" for CPT 11721 Every patient seen that has a 11721 has been rejected by Fidelis. When we call Fidelis they say we do not have a secondary diagnosis on the claim. But we do have a secondary on the claim. I have been working with our local representative for months with no resolution to this Fidelis system issue. Issue 2 - Fidelis has not updated post op period to zero for amputation CPT® 28820 and 28825 global periods. January 1, 2021, the postoperative global period for these procedures changed to zero days.- This update by CMS was implemented almost 2 years ago. All our post op visits are being denied. Again working with claims department and our local representative have not yielded any results. Appreciate your assistance with these ongoing issues.

In regard to the first question, if there is a discrepancy about the number of diagnosis codes being submitted to what is being processed, this should be appealed to Fidelis. Any line item (whether it’s submitted electronically or on paper) can accommodate up to four diagnosis codes per line item. When appealing, a copy of the claim should be submitted along with the EDI report of each denied claim that shows that the claim was accepted for processing with each of the diagnosis codes submitted for each claim in question.

For the second inquiry, if Fidelis has not updated the global period in their system for these two procedures, they will also need to be appealed. In this instance, in addition to including supporting documentation to demonstrate medical necessity, documentation should be included from CMS or another source to show that CPT codes 28820/28825 do not have a global period.

We are forwarding this issue to our Insurance Committee however, until these edits are revised, appeals are the only option.