Author Topic: Blue Shield Denial of 99213  (Read 1842 times)

stacykelley

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Blue Shield Denial of 99213
« on: November 11, 2013, 01:14:10 PM »
I work for a Chiropractor, and Blue Shield has started rejecting the Office Visit code 99213 stating it is not a covered benefit under the patient's policy.  The doctor only uses it when the patient hasn't been seen for a long time and he needs to reassess their condition.  If the denial stated it wasn't medically necessary, I would appeal it... but not a covered benefit?

The doctor said that it is illegal for insurance companies to discriminate covered benefits depending on the specialty, but I have no documentation to support this so I can appeal.  Does anyone have any insight into this?

DMK

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Re: Blue Shield Denial of 99213
« Reply #1 on: November 11, 2013, 01:29:10 PM »
We ran into this too.  I called Provider Relations and was told that the Chiropractor on their advisory board said that "a Chiropractor would never need to bill a 99203 or 99213 as Chiropractors don't deal with cases with that level of complexity".   So it's only ok to bill 99202 (new patient) or 99212 (re-exam existing patient).

B.S. right?  But that's what they're doing.  Never mind that MANY things present as back pain and it takes a thorough exam and case management to weed through the symptoms. 

We've sent people to the ER for DVT's, heart attacks, gall bladder attacks, labor.  I think that qualifies for the higher complexity and medical decision making!  And what about the patient with 3 prior surgeries and a laundry list of medications and past history? 

I'm as frustrated by this as you are, and told Provider Relations.  But their "advisor" holds the power.  And over his own fellows too!


PMRNC

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Re: Blue Shield Denial of 99213
« Reply #2 on: November 11, 2013, 01:39:48 PM »
On the flip side of this.. I went to TWO chiropractors a long time ago and both tried to bilk me and my insurance company saw him 5 times and NOT once did he mention possibility of a kidney infection.. NOT once. BOTH billed E/M codes
Linda Walker
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