Working Coding Related Denials

NYU FGP AR TIP Sheet

August 3, 2021

When working denied claims; there are certain coding related denials that can be handled by the
AR Representative without having to escalate to the Coding Team.
NOTE: All coding changes for Radiology Department must still be sent to Radiology Coding team for review and
approval.
This tip sheet will walk you through the steps to troubleshoot basic coding related denials.
The following Denials have guidance is this Tip Sheet please note that the remit codes may not be listed of may vary
from what is represented here:

• Consult Code Denials ‘Consult code not accepted’

• New Patient Qualifications Not Met (B16)
• New Patient Preventative Visit Denial
• Included in Procedure
o Smoking Cessation CPT (99406 or 99407)
o E/M & Vaccine or Drug
o Screening Services
• CLIA / Lab missing QW modifier or added in error (B7)
• Admin code not covered (PR204)
• Tetanus Vaccine (CPT 90714/90715) (PR204 or PR49)
• Patient Enrolled in Hospice (PRB9)
• Bilateral Modifier 50 vs LT/RT
• Physical Therapy Modifiers GP/GO & Speech Pathology Modifiers
• S0285- Consult before Screen Colonoscopy (CO-189- Incorrect Procedure Code Billed)
• G0180-MD Certification HHA Patient (CO234-Procedure not paid separately)

• Vaccine Administration Denials for Add on Admin Code 90461

• Non Covered Service; related to Behavioral Testing CPT 96110
• Place of Service Denials; related to Telemedicine
• Flu Shot Denial with rejection reason ‘Inconsistent with (or ineligible due to) Patient’s Age
• Medicare Annual Wellness Visit Denials; related to code G0438 (PR119)

WORKING CODING RELATED DENIALS AUGUST 3, 2021 1

Consult Code Denial

Denial Reason; Consult codes not accepted. While EPIC does have edit rules in place in our Charge Review WQ’s,
in some cases these edits are bypassed by the BC’s (they are not a red/hard edit unfortunately) resulting in the claim
being released to the payers. These denials we can be addressed by the AR Representative without having to forward
to the coding team for advisement.

By using the crosswalks below as our guide we can determine the correct E/M code based on the patient’s status (New
versus Established) and the claim’s POS billed (In-Patient versus Out-Patient/Office).

It is important, however, to remember the following:

 This correction should only be made in the instances where a payer is stating they no longer accept consult
codes.
o If the consult code is being denied for frequency, this will need to be reviewed in further detail to
determine if the patient was seen by another provider of a different specialty on the same day. In this
instance, the consult code should be appealed given the fact that the providers are of a different
specialty and more than one consult may be able to be performed.
 If the carrier, however, states they only allow one consult per day; then you would follow this
crosswalk to charge correct the claim to the most appropriate New or Established patient CPT
code accordingly.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 2

New Patient Denial
Denial Reason; New Patient Qualifications not met;
B16-COB16-DENIED/RDCD, NEW PAT QUALIF NOT MET.
A thorough review of Tx Inquiry is necessary to determine the following:
1. Was this patient seen before by the same provider in the last 3 years?
2. Was this patient seen before by another provider of the same specialty & Tax ID within the last three years?
If the answer is yes, you can proceed with charge correcting your claim to the appropriate established patient visit
following the crosswalk below:

* Please note CPT 99201 does not crosswalk to CPT 99211. The appropriate crosswalk is to CPT 99212.
* Please also note that as of 1/1/2021 CPT 99201 is now a deactivated code. You should not encounter any
denials with a date of service on or after 1/1/2021 for CPT 99201. (If you do; this should be escalated to coding
for further review).
If your answer is no, the patient has NOT been seen by the same provider and/or another provider of the same specialty
within the last three years; then the claim must be appealed with the payer.
Oftentimes, a New Patient CPT code will deny against another New Patient CPT code of a provider of a different
specialty or subspecialty. These claims must always be appealed.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 3

New Patient Preventative Denial
If a New Patient Preventative visit (99381-99387) is denied stating the patient is not in fact a new patient of the
practice; the same verification steps as noted above should be completed to confirm whether or not the patient is truly a
new patient of the provider/specialty. If the patient is not truly a new patient; the below crosswalk can be followed to
charge correct the claim to the appropriate established patient Preventative Visit.

** Please note that this crosswalk cannot be utilized for Medicare or Managed Medicare plans.

Preventative Visit Crosswalk

New to Established Patient

Age Range New Patient Established Patient

Less than 1 year old 99381 99391
Age 1-4 years 99382 99392
Age 5-11 years 99383 99393
Age 12-17 years 99384 99394
Age 18-39 years 99385 99395
Age 40-64 years 99386 99396
Age 65+ 99387 99397

***Please note that Medicare and Medicare Managed Care plans do not accept these codes.***
If a Medicare or Managed Medicare patient is seen for a 'Well Visit' we would potentially need to
utilize the Medicare AWV codes; however, this will need to go to coding to determine if the
provider's notes support changing the code.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 4

Included in Procedure Denials

There are many different coding scenarios that would result in an ‘included in procedure’ denial.
Below are some of the most common ones and how to address:
-An E&M service billed with a Smoking Cessation CPT (99406 or 99407).
If either CPT deny as included in procedure to the other CPT code; review the patient’s office visit note for the
applicable date of service to determine the following:
Is there a statement by the provider attesting to tobacco counseling where he/she indicates how much time was spent
counseling the patient on the use of tobacco?
Example:

If the answer is yes, a 25 modifier can be added to the E&M code in order to separate this service from the tobacco
counseling service.
If the answer is no; this invoice should be escalated to Coding for further review.

*** In the event that the Tobacco Counseling code was paid and the E&M code that is being denied as included in
procedure; and it is determined that the provider did not attest to the amount of time spent counseling the patient on
tobacco use; the smoking cessation CPT code should be routed to coding team suggesting that it be voided the E&M
code should be pursued for payment with the payer.

*** Please note that many insurance carriers have policies regarding Smoking Cessation services being bundled into
an E&M service; typically when the patient is seen for a preventative exam. If you find that the claim has been denied
and a 25 modifier is already on the E&M service; review the specific carrier’s policy as this is likely truly a bundled
service that will need to be adjusted.
Smoking Cessation during Annual Physical Visit:
UHC and Oxford have a policy that smoking cessation services will always be bundled into a Preventative Visit
(99384-99387; 99394-99397) regardless if a modifier 25 is added. In these cases, we should not charge correct the
claim to add the 25 modifier (if it is not there); these can simply be adjusted as bundled- Procedure/Services Bundled
using w/o code 3023
Carrier Policies:
https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/COMM-Preventive-
Medicine-and-Screening-Policy.pdf
https://www.oxhp.com/secure/policy/preventive_medicine_and_screening_policy.pdf

WORKING CODING RELATED DENIALS AUGUST 3, 2021 5

Included in Procedure Denials
-An E&M service billed with a vaccine

Oftentimes, a patient will come in Preventative Exam and will receive vaccine on the same day.
If the E&M code is denied as included in procedure because it is being bundled against the vaccine administration
code. Review the patient’s office note to determine if they were strictly there for the vaccine or if the documentation
supports that the patient’s visit was for the Preventative Exam and the vaccine occurred as incidental.

Here is an example. The introduction to the note indicates the patient presented for an annual physical on this date.
The provider subsequently states that she happens to also be due for a flu vaccine. The body of the note itself includes
a complete ‘Review of Systems” and ‘Physical Examination’ which support the Preventative visit being billed. The
provider also documents separately the fact that he administered the influenza vaccine. These are two separate
services and a 25 modifier can be added to the E&M code.

*** If the note is unclear or you are unable to ascertain whether or not the patient simply came in for the
vaccine or whether the visit was a separate service, this should be escalated to coding for further guidance.

*** If the note indicates – the patient is being seen for a vaccine ONLY today; this may mean the E&M code
may not be warranted. These instances should always be escalated to coding for further review before adding
any modifier to the claim.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 6

Included in Procedure Denials
Many insurance carriers deem certain ‘screening’ services to be inclusive of the Preventative Visit billed on the same
date (even if the Preventative visit has a 25 modifier).

Preventative visits include CPT range 99391-99397 or 99381-99387.

If the provider bills a Preventative visit and also bills for one of the ‘screening’ services listed below, the carrier may
deny the service as ‘not paid separately’ or ‘included in procedure.’
If you encounter a denial for one of the services listed below where a Preventative Visit was also billed; confirm within
the payer policy links provided to determine if this service is in fact deemed inclusive according to that payer policy. If
it is, then it is okay to proceed with the adjustment for ‘not paid separately’ or ‘included in procedure’ respective to
how the payer denied the claim.

Visual Screening Services

CPT 99172 Visual function screening, automated or semi-automated bilateral quantitative determination of visual
acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision
CPT 99173 Screening test of visual acuity, quantitative, bilateral
CPT 99174 Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote
analysis and report

Prostate Cancer Screening

CPT G0102 Prostate cancer screening; digital rectal examination

Pulse Ox
CPT 94760 Noninvasive ear or pulse oximetry for oxygen saturation

(This service may be billed with a Preventative Visit OR a New Patient/Established Patient visit.
Regardless of which E&M code it is billed with, it will be bundled and can be adjusted using
adjustment code 3023).

Oxford: https://www.oxhp.com/secure/policy/preventive_medicine_and_screening_policy .pdf

United Healthcare: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-
reimbursement/COMM-Preventive-Medicine-and-Screening-Policy.pdf

Oxford and United Healthcare are the most common payers that will bundle these services; however, if you
encounter other plans that do as well, please provide this information to your Manager so that we can add any
additional payers as applicable.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 7

CLIA / Lab Denials for Missing QW Modifier
(or potentially where QW Modifier was added and shouldn’t have been).

If a practice has a CLIA waiver; they will be allowed to perform lab services in the office setting as long as the service
has a CLIA waived status per CMS. Below is the link to the CMS file that will provide the full list of tests that are
granted waived status under CLIA.

* Please note that there are a small number of CLIA waived tests that do not require the QW modifier to be appended;
therefore, if a QW modifier is inadvertently added; these services will be denied.

The denial reason you will find if the lab code is missing the QW modifier or where it has been added and shouldn’t
have been will be: B7-COB7-PRVDR NOT ELIG 4 PMT ON DATE OF SVC.

If it has been confirmed that the practice has a CLIA waiver; refer to the link below to determine if the QW modifier is
required (or not) so the claim can be charge corrected accordingly to either add or remove the QW modifier.
https://www.cms.gov/files/document/r10397cp.pdf
If denial is received that the CLIA number is missing from the claim, escalate to management for clarification to
determine if practice has a CLIA waiver for the procedure.
https://www.wadsworth.org/regulatory/clep/limited-service-labs

** When reviewing a Medicare denial of B7-COB7-PRVDR NOT ELIG 4 PMT ON DATE OF SVC; be certain to
review the entire claim.
• If all CPT’s on the claim denied for this rejection reason; this would mean there is an issue with the provider’s
credentialing. It should be verified in Cactus when that provider became par with Medicare. This would need
to be reviewed by management for potential adjustment or to escalate the issue to Credentialing.
• If ONLY the lab CPT’s (8,000 series codes) were denied; then this validates that the issue is related to a
missing or invalid QW modifier OR that the provider is providing a service that falls outside the limitations of
the CLIA waiver certificate. (If it is the latter – this will need to be reviewed by management.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 8

Administration Code Denials from Medicare
for Covered Medicare Vaccinations

Medicare covers the Flu, Pneumococcal and Hepatitis B vaccinations. There are specific ‘G’ codes that must be billed
as the corresponding administration code. (They will not cover CPT 90471 as the administration code for these three
vaccines). This also applies to Railroad Medicare in addition to the managed Medicare plans (such as Blue Senior,
Aetna Medicare, Humana Medicare, etc.)
Flu Vaccine Administration Code G0008
Pneumococcal Vaccine Administration Code G0009
Hepatitis B Vaccine Administration Code G0010
In the event that CPT 90471 inadvertently gets billed along with one of these three vaccines for a Medicare or
Managed Medicare patient; Medicare will deny the 90471 as:
PR204-SVC/EQUIP/DRUG NOT CVD UNDER PLAN
It will be necessary to charge correct the claim in EPIC to correct the administration code from 90471 to the
corresponding ‘G’ code; dependent upon the vaccine given. For Medicare, the claim cannot go out electronically and
must be handled as a reopening on Connex as they will erroneously deny this type correction if sent electronically.

https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventive-services/mps-quickreferencechart-
1.html
The above link is a great Medicare tool that details the guidelines for vaccine administration.
Reference the following for additional guidance:

Flu Shot & Administration

Hepatitis B Shot & Administration
Pneumococcal Shot & Administration

Medicare Denials for Tetanus Vaccine

The Tetanus vaccine is only considered a covered service if it is given as a result of an injury.
CPT 90714/90715 and administration code 90471 when it is denied by the payer for:
PR204 SVC/EQUIP/DRUG NOT CVD UNDER PLAN; or
PR49 NON-CVD, SCRNING IN CONJ W/RTN EXAM
The following link will take you to the detailed workflow on SharePoint titled:
Medicare Part B: Tetanus Vaccine Denial Workflow
https://central.nyumc.org/shared/site/FGP/CBO/AR%20Tip%20Sheets/Workflows%20and%20Processes/Medicare/M
edicare%20Part%20B%20-
%20Tetanus%20Vaccine%20Denial%20Workflow%202020.docx?d=w2348896bd99b4a1c8f81d5071d39e18a&csf=1
&e=XjIlno

WORKING CODING RELATED DENIALS AUGUST 3, 2021 9

Hospice Denials
When a patient is enrolled in Hospice all services they receive require a modifier because a patient has waived their
Medicare Part B payment for any treatment of terminal illness during the hospice period.

However there is an exception for the provider who attends the patient, who is not an employee of the hospice and is in
no way attached to the hospice.
We typically do not know that a patient is enrolled in Hospice until we receive the denial from Medicare:
PRB9 – NOT CVD, PATIENT ENROLLED IN HOSPICE
To correct the claim, one of the below two modifiers will need to be appended:

The GV should be appended to the claim if the provider is not employed by the Hospice.
The GW should be appended to the claim to identify when the patient’s condition for hospice care is not related to
the service being provided on our claim.

For example a patient on Hospice due to end stage breast cancer but is receiving services for an unrelated
gastrointestinal issue.
NYU providers are not employed by a hospice facility therefore GV modifier will always apply regardless of the
patient’s diagnosis.
To confirm denial is accurate log into Connex to check the patients History of admissions/discharges from SNF before
updating with GV modifier.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 10

Bilateral Modifier 50 vs. RT (Right) and LT (Left) Modifiers
Certain carriers require the use of the 50 modifier (as opposed to using the RT/LT modifiers) when bilateral services
are being reported (for a service where the CPT description indicates unilateral reporting). Payor list below includes
the carriers that prefer modifier 50 to be reported for bilateral services.
In the event the wrong modifier is used; the carriers will typically deny the claim with a denial reason of:
Procedure/Modifier not compatible with another Procedure/Modifier combination.
As in the example below, this CPT was reported on two separate lines; once with the LT modifier and once with the
RT modifier. The correction will require deleting one of the lines and correcting the other line to reflect modifier 50
instead of modifier LT or RT. (Be mindful of any other modifiers that are reported on the claim as they would not
necessarily need to change).

PAYOR MODIFIER 50 WARNING

Aetna Modifier 50 present When billing a bilateral procedure, enter the code on a single claim
line with modifier 50 and a quantity of 1.
Cigna Modifier 50 present When billing a bilateral procedure, enter the code on a single claim
line with modifier 50 and a quantity of 1.
EBCBS Modifier 50 present When billing a bilateral procedure, enter the code on a single claim
line with modifier 50 and a quantity of 1.

Emblem (GHI, Modifier 50 present When billing a bilateral procedure, enter the code on a single claim
HIP) line with modifier 50 and a quantity of 1.
Medicare Modifier 50 present When billing a bilateral procedure, enter the code on a single claim
line with modifier 50 and a quantity of 1.
OXFORD /UHC Modifier 50 present When billing a bilateral procedure, enter the code on a single claim
line with modifier 50 and a quantity of 1.

Local 1199 Modifier 50 present When billing a bilateral procedure, enter the code twice on two
separate claim lines, once with modifier LT and once with modifier
RT
United Modifier 50 present When billing a bilateral procedure, enter the code on a single claim
Healthcare line with modifier 50 and a quantity of 1.

Health First Bilateral Indicator 1 When billing a bilateral procedure, enter the code twice on two
and Modifier RT, LT is separate claim lines, once with modifier 50 and once without.
present
Health First Bilateral indicator 3 When billing a bilateral procedure, enter the code twice on two
and Modifier 50 is separate claim lines, once with modifier 50 and once without.
present Or may use one line with both RT,LT modifiers

WORKING CODING RELATED DENIALS AUGUST 3, 2021 11

Physical Therapy Modifiers
Many payer policies require that modifier GP or GO be added to Physical Therapy and Occupational Therapy services,
ex. CPT 97110, 97140, 97112
GP Modifier:
Modifier GP denotes services that are part of an outpatient Physical Therapy plan of care.
The provider carries out the service in an outpatient setting.

GO Modifier:
Services delivered under an outpatient Occupational Therapy plan of care

There is a rule built within EPIC to automatically add the applicable modifier for those payers where we are aware this
is a mandatory requirement (Ex: Cigna, United Healthcare, Oxford).
In the event you receive a claim denial and it is determined that the GP or GO modifier is missing from the claim and
this is the reason for the denial; it would be appropriate to correct the claim to append the applicable modifier based on
the Provider type of the Billing Provider.
If a new payer policy is identified where either of these modifiers become mandatory – this should be brought to
management to amend the existing EPIC rule.

Speech Pathology Modifiers

The GN modifier is used in instances for Speech Therapy services.
GN Services delivered under an outpatient speech-language pathology plan of care
The most common service that is performed in our Pediatric practices is the below CPT code:
CPT 92526 Treatment of swallowing dysfunction and/or oral function for feeding.
This claim should go out with the GN modifier already appended; however, if it does not and the carrier denies the
claim with an indication that this modifier is required; the claim can be charge corrected and this modifier can be
appended by the AR Representative.

S0285 –Gastro Consult

Some payors do no cover the S0285-Before Colonoscopy Screening Consults. Edits haven been put in place for
the specific plans that we’ve confirmed do not cover but for plans that do not get caught in the edit, you may
find that they reject. Typical denial code is CO-189- Incorrect Procedure Code Billed. These can be adjusted as
Procedure/Services Bundled w/o code 3023.

G0180-MD Certification HHA Patient

This procedure is not payable by BCBS. When denial is received it will typically have denial code CO234-
Procedure not paid separately. Adjust as Procedure/Services Bundled using w/o code 3023. The carrier
considers this inclusive in the surgical procedure billed prior to this code.
The HHA Certification should be located within the Episode Tab of Media Manager
For any other denials related to this service, these claims should be escalated to coding for further review.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 12

Vaccine Administration Denial:

CPT 90461 - PR IMADM THROUGH 18YR ANY ROUTE EA ADDL VAC/TOXOID

Medicaid and Medicaid managed care plans do not cover the ‘add on’ code CPT 90461. This code is used to indicate
when the vaccination administered has more than toxoid.
The below four vaccines will be the most common Pediatric vaccines where CPT 90461 will be billed.
CPT 90715, 90700, 90698 & 90696 each have more than one toxoid being administered and therefore CPT 90460
would be billed (and paid) for the initial toxoid and CPT 90461 would be billed anywhere (from 2-4 units, depending
on the vaccine given) for the additional toxoids.
Commercial carriers will reimburse for CPT 90461.
Medicaid and Medicaid Managed care plans (Affinity, Fidelis, Healthfirst, Health Plus, etc) will deny CPT 90461 as
non-covered or bundled and in these instances, it is okay to adjust using the respective denial code of non-covered or
bundled (respective to the denial reason from the payer).

WORKING CODING RELATED DENIALS AUGUST 3, 2021 13

Non Covered Services
There are payers that deem certain Pediatric Behavioral Health services to be considered non-covered.
Fidelis does not cover for Developmental Screening service, CPT 96110. Below is the link to this payer policy. If you
receive a denial for this service, it can be adjusted as a non-covered service, per the payer policy.
CPT 96110 Developmental screening (e.g., developmental milestone survey, speech and language delay screen),
with scoring and documentation, per standardized instrument
https://www.fideliscare.org/Portals/0/Providers/AuthorizationGrids/2020-08-FidelisCare-Medicaid-
AuthorizationGrid-English.pdf

WORKING CODING RELATED DENIALS AUGUST 3, 2021 14

Place of Service Denials; related to Telemedicine
Telehealth Services-Payers have different requirements for modifier and POS type. Some payers are now requesting
that a telehealth service have POS type 02. If you find that a claim has been denied for this reason, you will need to
view the claim to confirm that POS type is inconsistent with that payer’s telehealth claim policy.
The claim will typically deny with denial reason: CO5-PX/BILL TYPE INCONSISTENT W/ POS.

If the POS needs to be corrected you will need to use Charge Property Override when making the correction

Once Charge Property Override is selected, enter the 02-Telehealth in the POS Type field

To verify how the payer wants the Telemedicine claim reported; review Telemed Payor Grid in Panviva.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 15

Flu Shot Denial; specific to denial reason:
Inconsistent with patient’s age [CO6] or Not Elig due to patient age
There are no scenarios where a patient should receive a vaccine outside of the recommended age criteria since vaccines
are not FDA approved outside of recommended age criteria
We must review chart to see what vaccine was actually administered to the patient
Navigate to chart and the encounter and look for “immunizations given” box, hovering provides some information but
not all that we need.
Click on the blue hyperlink.

Now we can see the manufacturer and the NDC# of what was administered

Use the influenza guide for the appropriate year to match to the appropriate CPT

WORKING CODING RELATED DENIALS AUGUST 3, 2021 16

Medicare Denials for Annual Wellness Visit (G0439); Max Benefits Reached PR119

Annual Wellness Visit

https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventive-services/mps-
quickreferencechart-1.html?#AWV
G0439 Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit.

(This service would be billable when a patient is outside of their effective date with Medicare by 2
years.
• Year 1 would be Initial Preventative Exam (G0402).
• Year 2 would be Annual Wellness Visit; initial (G0438).
• Year 3 would be Annual Wellness visit; subsequent (G0439).

If we receive a denial from Medicare for G0402 or G0438 where they are denied as Max Benefits Reached (PR119) or
Lifetime Max Benefits Reached (PR149) these will always need to go to coding for review to determine if an alternate
code is billable.
If we receive a denial from Medicare for G0438 with a denial reason of PR119 – Max Benefits Reached; the following
review should occur to determine appropriate next steps:
1. Review invoice history to determine last time service was billed. If billed within the last 12 months; the patient
would not be eligible to receive this service again.
o Review all services provided on this same date by the same provider. If no other E&M service was
billed on this date (99212-99215, 99202-99205); this invoice should be escalated to coding for them to
determine if a new/established patient E&M code can be billed in place of the Annual Wellness Visit
code.

o If there is another E&M code also billed on this same claim (99212-99215, 99202-99205); then there
is nothing additional for coding to review and in this case, the G0439 code should be voided by a
Supervisor or Manager.

WORKING CODING RELATED DENIALS AUGUST 3, 2021 17