Claim denied as - inclusive, maximum per unit, injury liablity and pre existing

Claim denials for maximum units per visit

Check your units of the CPT. Check LCD Guidelines for Maximum unit. We can appeal the claim with document supports for additional units of service.

Sometime claim submitted with wrong units by mistakes, correct the unit and resubmit the claim.

Dialysis Services requires one service line per a date of service with a maximum unit of one for dialysis services. If a claim is received with a date span billing multiple units on a single charge line, the charge line will be denied


Claim denied as inclusive with the primary procedure

Some service covered with primary procedure, Hence we needs to taken write off the claim balance after primary CPT paid. However there is chance with resubmit the inclusive procedure with modifier.

Check whether its a mutually inclusive CPT, If not resubmit with appropriate Modifier or changes in ICD code. If it is Bundled CPT code, please write off it.






Mutually inclusive

 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one  that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. An assumption of same anatomic site is made during the auditing process. Due to previous  treatment, if foreign materials such as nails, rods, or screws were implanted, their removal may be required during a current primary surgical intervention. Also, the implanted wires, pins, screws, or rods located in the operative site  may now be causing pain or infection. Thus, removal of previously implanted devices/materials is clinically integral to the successful outcome of the primary procedure and do not warrant separate reimbursement. This logic is  supported by the CMS guideline for Fractures found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter IV that states, "There are CPT codes (20670 and 20680) for removal of internal fixation devices (e.g., pin,  rod). These codes are not separately reportable if the removal is performed as a necessary integral component of another procedure. For example, if revision of an open fracture repair for nonunion or malunion of bone requires removal  of a previously inserted pin, CPT code 20670 or 20680 is not separately reportable."




What are the Column 1/Column 2 PTP Code Pair Tables?

Although the Column 2 code is often a component of a more comprehensive Column 1 code, this relationship is not true for many edits. In the latter type of edit, the PTP code pair edit simply represents two codes that should not be reported together, unless an appropriate modifier is used. For example, a provider should not report a vaginal hysterectomy code and total abdominal hysterectomy code together.

Many procedure codes should not be reported together because they are mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same beneficiary encounter.

An example of a mutually exclusive situation is the repair of an organ that can be performed by two different methods. Only one method can be chosen to repair the organ. A second example is a service that can be reported as an initial service or a subsequent service. With the exception of drug administration services, the initial service and subsequent service cannot be reported at the same beneficiary encounter.

In addition, the descriptor of some HCPCS/CPT codes includes a gender-specific restriction on the use of the code. HCPCS/CPT codes specific for one gender should not be reported with HCPCS/CPT codes for the opposite gender.
Claim denied due to pre-existing condition
Member has Preexisting Condition on DOS for Diagnosis

Patient needs to update the medical (medical history) document to insurance and provider also update the medical document to insurance. as soon as you receive the denial,  check with insurance on the pre-existing condition. If the patient has secondary coverage with the secondary if we can send the entire bill to secondary along with the primary denial.  Some carriers may be willing to pay for the same.  If the patient has no secondary coverage/ secondary refused to pay the request you to bill the patient.



Claim denied as services not provided or authorized by designated

File the claim along with appropriate authorization#. Check all the documents as sometime Authorization number has been mentioned in Medical record. If we don’t have authorization# sometimes we can appeal the claim along with necessary medical document.




Claim denied because of incorrect medical coding
Should be file the claim with correct diagnosis (Dx) and CPT



Claim denied because this injury is the liability of the no-fault carrier.

Should be file the claim to patient auto-insurance.



Claim denied by medicaid because primary insurance changed
File the claim to patient primary insurance. If we don’t have patient primary insurance details needs to call the patient and get the insurance information.



Claim denied by medicare for code co-16 what do i do to get this paid?
      We will receive this denial if we have filed the claim with insufficient information. This code co-16 must have additional denials information that informs us what kind of information is missing with claim.





Claim denied for clia certification#
Should be file the claim with clia certification number. We must file the lab code with clia number.