7: The procedure/revenue code is inconsistent with the patient's gender

On Call Scenario:

                                                  Claim denied as Procedure code is
                                                   inconsistent with patient's gender
                                                                           ↓
                                                        May I get the denial date?
                                                                           ↓
                                                Check patient payment history if
                                            the same CPT paid by same insurance
                                               ↙                                                      ↘
                                         Yes                                                           No
                                           ↓                                                               ↓
              Can you please reprocess the claim as               What is the time limit to 
                  payment received for same CPT?                     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:

• There are few gender-specific CPT. For example, CPT 77067 (Breast Mammography) can only be billed for females. If it is incorrectly billed for Male then will get this denial.
• When getting this denial, always check patient eligibility since gender could be updated incorrectly while updating patient information then update the correct gender information and resubmit the claim.
• If the patient's gender is also correct on the website then this denial should be assigned to the coding team to review and provide the correct procedure code. Once a response is received with the correct CPT details then submit the corrected claim to insurance by updating the correct CPT code 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 procedure code is coded correctly 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.

Prepare Notes:

Source of Status:

* Call Website EOB System

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 in the patient payment history?:

* Yes No

What Information is Available?:

* Corrected Claim Time Frame Appeal Information Corrected Claim Time Frame and Appeal Information None

TAT for Reprocessing:

*

Corrected Claim Time Frame:

*

Mode of appeal:

* Fax Mail Website

Fax Number:

*

Mailing Address:

*

Website Link:

*

Appeal Limit:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Need coding assistance Updated correct gender and resubmitted the claim Updated correct procedure and resubmitted the claim Need client assistance Need to send an appeal Need to allow time Appeal Sent



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