4: The procedure code inconsistent with the modifier used or a required modifier is missing
On Call Scenario:
Claim denied as procedure code
inconsistent with the modifier used
↓
May I get the denial date?
↓
Claim denied as procedure code
inconsistent with the modifier used
↓
May I get the denial date?
↓
Check patient payment history if the same
CPT code paid with the same modifier
↙ ↘
Yes No
↓ ↓
Can you please reprocess the claim as What is the time limit to
payment received for same CPT & modifier? send corrected claim?
↓ ↓
What is the TAT for reprocessing? What is the Fax# or Mailing
↓ address to send an appeal?
May I have the claim# & call ref#? ↓
How much is the time limit
to send an appeal?
↓
May I have the claim# & call ref#?
Important Note:
Yes No
↓ ↓
Can you please reprocess the claim as What is the time limit to
payment received for same CPT & modifier? send corrected claim?
↓ ↓
What is the TAT for reprocessing? What is the Fax# or Mailing
↓ address to send an appeal?
May I have the claim# & call ref#? ↓
How much is the time limit
to send an appeal?
↓
May I have the claim# & call ref#?
Important Note:
- This denial should be assigned to the coding team to review and provide the correct modifier and once a response is received with the correct modifier details then submit the corrected claim to insurance by updating the correct modifier if the time limit to submit the corrected claim is not crossed.
- Sometimes the client wants us to submit the corrected claim even if the time limit is crossed, so work accordingly.
- If the coding team states that the modifier is correct then send an appeal to insurance.
- When sending an appeal, calculate the time limit from the denial date, if it is not crossed then send the appeal, or else write off the claim if the time limit is crossed.
- Sometimes the client wants us to send the appeal even if the time limit is crossed, so work accordingly.
- There will be a scenario where the same CPT is billed with the LT and RT modifiers and one of them is already paid and the other is denied as an invalid modifier, in that scenario insurance needs to send the CPT in a single line by using bilateral modifier(50). So void both the CPT and create a new line with a 50 modifier which will double the charge amount and send the corrected claim to insurance.
- Medicare does not accept the corrected claim, so first send the void claim for paid CPT to insurance then send a new claim with a 50 modifier.
Prepare Notes:
Source of Status:
Clearing House Comment (Please make the changes if required):
Insurance Name:
Clearing House Name:
Insurance Phone#:
Rep Name:
Website Name:
Denial Date:
Has payment found for the same CPT with same modifier in the patient payment history?:
What Information is Available?:
TAT for Reprocessing:
Corrected Claim Time Frame:
Mode of appeal:
Fax Number:
Mailing Address:
Website Link:
Appeal Limit:
Additional Comment:
Claim Number:
Call Reference#
Action:
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Hey i would like to aprct your efforts
ReplyDeleteIts been 8months since i am following your page.
And just because of uhr page
I have learned alot that helped me to grow jn this industry
I have q request for you
Can me make flow charts for dentalbilling
I am unable to get the jnfo kf dentalbilling
Dental denials
Thank you. We are really happy to hear that.
DeleteAnd regarding the dental denials, you should not be worried. Since you are working on AR, you will be getting the same denial that are listed above. In case you receive any new denial or unable to understand any denial please write us back, we will definitely help you out.
Really appreciative sir thanks for helping..
ReplyDeleteThank you!
DeleteHow to submit a void claim to medicare as when I'm trying to submit with resubmission code 8 and claim number its getting rejected in the clearing house with rejection stating medicare cannot accept resubmission code 7 or the void claim code 8
ReplyDeleteThere is an option to void a claim on call. Please connect with Medicare insurance rep to know the process of voiding a claim.
DeleteI have 1.5 years of experience in medical billing. I faced many problems when I was a fresher in this field. I found your page a couple days ago, and you guys are doing fantastic. God bless you.
ReplyDeleteThanks a lot!
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