Author Topic: recent denial of claims coded 99243 and 93971  (Read 946 times)


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recent denial of claims coded 99243 and 93971
« on: June 15, 2017, 10:08:48 AM »
we have been billing CPT 99243 (or other E/M codes)  and CPT 93971 for many years and have been getting reimbursed for both. During the last year of so, United Healthcare (NY) has stopped paying for CPT 99243 stating that this code requires a referral in order to receive reimbursement. Our surgeons are out of network so we don't need referrals for these out of network plans. Also, it had helped to use modifier 25 with 99243 and modifier 59 with 93971 but now this is no longer accepted. Has something changed?


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Re: recent denial of claims coded 99243 and 93971
« Reply #1 on: June 15, 2017, 08:20:00 PM »
Consultation codes (99241-99245) have not been allowed by most insurances for a few years now.  Medicare has instructed physicians to bill consultations using E&M codes.   It is still legal to bill them, but they are not reimbursable by most insurances. 
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Re: recent denial of claims coded 99243 and 93971
« Reply #2 on: June 16, 2017, 03:53:11 PM »
If you are dealing with an insurance that still allows consultation codes, it makes sense that they will deny them regardless of whether your providers are in or out of network if you don't have a referring provider listed on the claim. You can't have a consultation if you don't have a doctor who referred the patient to your provider for that consultation. It is one of the three "R's" needed for consultation codes.

As for the 25 and 59...
If you bill a 99xxx E/M with a 93971, you will need the 25 modifier on the E/M with almost every insurance I can think of. You do NOT need a 59 on the 93971 if all you are billing is the E/M with the 93971.