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Recent concerning billing issues

king22

Full Member
7+ Year Member
May 11, 2014
68
55
206
  1. Podiatrist
So today I had a little chat with our office manager. She alerted to me to some concerning trends she's noticed over the past 2 months-

1. Significantly increased denial rates for any claim billed with a modifier 25 by both BCBS and Aetna- To use an example, I had an initial patient visit for a right ankle sprain. I billed for a visit, x-rays, and a strapping. Upon f/u (3 weeks) later, the patient also complained of an ingrown nail. So I ended up performing a partial nail avulsion. My billing was a 99212 (connected to the sprain) and a 11730. BCBS paid the 11730, but not the 99212 stating that all services were included in the payment for the 11730. We appealed it and sent in notes (which clearly showed a separate treatment of the sprain including demonstration of ROM exercises, returning to light duty, etc) and they upheld their denial. I know BCBS's scrutiny of modifier 25 claims has increased, but usually when I sent in notes they would pay for the visit. This is also not a "one time" issue. At least a dozen claims recently have had this issue.

2. 17110 no longer covered is performed by a podiatrist under Aetna- This is arguably more concerning. Over the past few months I've had about half of my Aetna 17110 claims denied based on this reasoning.

3. DME denials based on "Same or similar"- I've been aware of Medicare's increased scrutiny on DME dispensing, as well as private insurers, but it seems private insurers have gone a bit too far- I've had multiple instances of where a night splint was dispensed to a patient for plantar fasciitis a couple of months prior to them returning for another issue in which another type of DME (brace/walker) was dispensed only to have it denied both on initial and appear under the "same and similar use". A specific case sticks out where I Dispensed a night splint for patient with right foot plantar fasciitis back in early 2019. I saw them in Feb. 2020 for a left foot pain that ended up being a non-displaced fracture of the 2nd metatarsal shaft which I dispensed a Cam-walker for. Both initial and appeal denied payment based on the "same or similar" device guidelines. Notes were sent in with the appeal

I'm wondering if anyone else is having these issues. These things have happened in the past but our office manager has never seen these amount of denials.
 

dtrack22

Full Member
10+ Year Member
Apr 21, 2008
2,424
1,781
276
  1. Podiatrist

youre lucky BCBS only started doing that recently and doesn’t do it to every claim. They started that down in TX 2 years ago. Claimed it was an error within their computer auditing/first pass software, because all claims with a 25 modifier were being rejected/denied by their system.They always paid (with interest) when notes justified the modifier on appeal, so it would really be in their best interest to fix “the bug” in their system. Weirdly, they still haven’t fixed a thing. All claims with 25 modifiers are rejected first pass by BCBS down in TX.

Still get paid for a 17110. That one should be the most worrisome in my opinion.

DME issue also exists down south and up north in the Midwest as far as I know.

If you can pit your patient against their insurance company, then you can usually get all of your legitimate claims covered/reimbursed. Though I’ve found high enough level appeals also usually go in your favor when they are for legitimate claims/services.
 
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