Appeal When A New Code Claim Isn’t Paid?

Should You Appeal When A New Code Claim Isn’t Paid?

HIPAA regulations are in place to prevent medical billing games. When current procedural terminology codes and ICD-9 codes are introduced, they have a certain effective date attached to them. This effective date states the very last day in which payers and providers must recognize the new code. It is illegal to deny claims for medical billing non-recognition.

Providers deny claims all the time. There are various reasons for claim denials. These can range from a non covered service, to not substantiating medical necessity for a service. However, it is against the rules to deny medical billing because their system doesn’t recognize an active CPT or ICD-9 code.

An example of this is if a payer denies a claim for the CPT code 90714 (Tetanus and diphtheria toxoids absorbed, preservative-free, for use in individuals 7 years or older, for intramuscularly use) because their system is not set up to handle the code. Since the effective date for medical billing on this code was July, 1 2005, the payers cannot deny for this reason. It is against the law and HIPAA regulations.

You want to make sure the payer is actually denying for non-recognition, however. There are many other reasons a payer could deny 90714 in medical billing. They may not have paid because the claim was submitted prior to the CPT effective date. This is acceptable. They also may have denied because the service is no covered on the insured’s plan. If both of these scenarios are ruled out, you can absolutely appeal the claim.

Make sure your medical billing personnel know when to spot fishy payer activity. A lack of payment for claims you should be reimbursed for is devastating. Unawareness in the medical billing field could lead to a loss of payment.

View all Articles by: Melissa Clark, CCS-P