199: Revenue code and Procedure code do not match

On Call Scenario:

                                                   Claim denied as revenue code and
                                                       procedure code do not match
                                                                           ↓
                                                        May I get the denial date?
                                                                           ↓
                                          Check patient payment history if the same

                                          CPT code paid with the same revenue code

                                        ↙                                                                          ↘

                                    Yes                                                                            No

                                      ↓                                                                               ↓

   Can you please reprocess the claim as payment            Can you suggest the correct revenue code

       received for same CPT & revenue code?                or CPT code? (Most of the time reps do not

                                      ↓                                              have this information but sometimes reps do

           What is the TAT for reprocessing?                               suggest correct information)

                                      ↓                                                                               ↓

           May I have the claim# & call ref#?                                   What is the time limit to

                                                                                                        send corrected claim?

                                                                                                                       ↓
                                                                                                    What is the Fax# or Mailing
                                                                                                      address to send an appeal?
                                                                                                                       ↓
                                                                                                    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 a coding team to review and please mention all the information and suggestion in the notes that are provided by the rep. This helps the coding team to provide the correct revenue code or CPT code.
• Once a response is received with the correct revenue code or CPT code then submit the corrected claim to insurance by updating the correct 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 revenue code and CPT code are 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 with same revenue code in the patient payment history?:

* Yes No

Has rep provided correct CPT or Revenue code?:

* Yes No

What correct details provided by rep?:

* CPT Code Revenue Code CPT & Revenue Code

CPT Code:

*

Revenue Code:

*

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 CPT and resubmitted the claim Updated correct revenue code and resubmitted the claim Updated correct CPT and revenue code and resubmitted the claim Adjust off the claim Need client assistance Need to send an appeal Need to allow time Appeal Sent



In the below box, final notes will be displayed once you click on Submit button and this box is editable, so you can make the changes as per the requirement

Note: We are not saving any of your inputs or notes in the backend