8: The procedure code is inconsistent with the provider type/specialty (taxonomy)

On Call Scenario:

                                                   Claim denied as the procedure code is
                                                 inconsistent with provider type/specialty
                                                                               ↓
                                                             May I get the denial date?
                                                                               ↓
                                                    What is the exact reason for denial?
                                                  ↙                                                        ↘
             Provider specialty is not                                     Taxonomy code is missing
       allowed to perform this service                                     in the claim form
                               ↓                                                                             ↓
          Check the provider specialty                                At which box# on claim form
                 on NPPES Website                                          taxonomy code is missing?
    (Click here to visit NPPES website &                                           ↓
      Just enter rendering provider's NPI                         Check the claim form if
      in NPI Number section and click on                   taxonomy code is available or not
    'Search' Button. you will get provider                 ↙                                                     ↘
     specialty under 'Primary Taxonomy'            Yes                                                        No
                       Section)                                            ↓                                                            ↓
                              ↓                              Can you please reprocess                            May I have the
       Verify specialty with CPT            the claim as information                          claim# & Call ref#?
                 ↙                       ↘                 available on claim form?
      Different                       Same                             ↓
             ↓                                ↓                          Rep agrees?
   May I have the           Can you please             ↓              ↘
claim# & Call Ref#?   reprocess the claim      Yes                 No
                                   as provider specialty       ↓                       
                                       is same as CPT?                            May I have the claim#
                                                                ↘         ↓                         & call ref#?
                                                               What is the TAT
                                                               for reprocessing?
                                                                            ↓
                                                            May I have the claim#
                                                                    & call ref#?

Important Note:
  • In CMS 1500 form, the rendering provider's taxonomy code is available in box# 24J above NPI and the billing provider's taxonomy code is available in box# 33b.
  • When the taxonomy code is available in CMS 1500 and the rep is still not able to find it from their end then resubmit the claim again, information may be missing due to some error.
  • When the taxonomy code is not available on the claim form then resubmit the claim to check taxonomy code still going on the claim form or not. If it is still missing then inform the same client.
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17 comments:

  1. i have Medicaid in the secondary and denied for same reason what can be the next step

    ReplyDelete
    Replies
    1. Check the taxonomy code available in the claim form or not at box# 24J and 33b. If the claim is crossed over by Medicare to Medicaid. Then you can simply resubmit the claim because the taxonomy code is sometimes missing on the crossed-over claim.

      Delete
  2. I have already resubmitted claim with claim form now claim denied for same reason

    ReplyDelete
    Replies
    1. After resubmitting the claim, did you check the taxonomy code is updated on the new claim form or not?

      If you can see the taxonomy code on the claim form then you can contact the insurance and clarify the denial reason and if it is still not updated then you can escalate this issue to your client.

      Delete
  3. How to verify CPT speciality with taxonomy

    ReplyDelete
    Replies
    1. You can visit the below website to find the specialty of a provider based on the taxonomy code. This will help you to speculate CPT specialty.

      https://www.findacode.com/tools/taxonomy-codes.html

      Delete
  4. what should be the next steps if taxonomy code is not available? or if it, then rep does not agree to reprocess, can I ask what's the tfl to send appeal?

    ReplyDelete
    Replies
    1. We don't think that appealing to such a claim will work instead you can find a way to update the correct taxonomy on the claim form or if the correct taxonomy is available then resubmitting the claim. If still receive the same denial then confirm the issue with the rep and inform the client to get the resolution. You can follow the below steps as per the requirement,

      If the taxonomy code is not available on the claim form then resubmit the claim to check taxonomy code is still getting billed on the claim form or not. If it is still missing then inform the same client.

      If the taxonomy code is available in CMS 1500 and the rep is still not able to find it from their end then resubmit the claim again, information may be missing due to some error.

      Delete
  5. If the provider specialty is different from the CPT then we need to change the CPT? or need client assistance.

    ReplyDelete
    Replies
    1. No, you don't need to change the CPT. You can ask for client help.

      Delete
  6. how to check the speciality of the CPT to match with Providers NPI speciality.

    ReplyDelete
    Replies
    1. You can check the provider's specialty on the NPPES website.

      https://npiregistry.cms.hhs.gov/search

      Then, match the specialty with the CPT from the ranges listed on the below link.

      https://www.arlearningonline.com/2020/01/current-procedural-terminology-cpt.html

      Delete
  7. Can you please guide about Daniel of surgery code crosswalk to anesthesia code ?

    ReplyDelete
  8. Hi, the provider specialty type is Family and the specialty of the CPT falls to Pathology and Laboratory Services. In this case can the denial 'Provider specialty is not allowed to perform this service' be considered as correct?

    ReplyDelete
    Replies
    1. A provider with a specialty family medicine is allowed to order and interpret lab services. Please share the CPT codes.

      Delete
  9. We have received a denied from Cigna stating the provider is not certified to perform the service on the date, we confirmed the insurance states that the provider's specialty is different but we checked from our side the specialty is same the rep refused to reprocess the claim, what can we do in this case?

    ReplyDelete
    Replies
    1. You can ask the ins rep what specialty can they see in their system. If it matches with CPT then they will reprocess the claim. If they deny then ask for the reason for not reprocessing and the next step to get this claim reprocessed.

      Delete