Wiki - Payer won't pay NP as a 99204 or 99215 (2024)

What is the denial reason and who are the insurance payers? Have you found the payer policies that explicitly state they do not reimburse CPT code 99204 (and presumably 99205) or 99215 when performed by a NP? Sometimes the rationale in the payer policy can help you figure out what to do.

The short answer to your question is that you have to code the services to match what was done. If the NP performed a service that correctly codes to 99204 or 99215, then that is what you bill. Intentionally undercoding can constitute fraud. However, if the NP's documentation supports 99203 or 99214, then that is what you should code from the start. If you have complicated patients that are going to get coded as 99204 or 99215 and the insurance payer doesn't cover that level of service when performed by a NP, then you may want to schedule those patients with that insurance carrier with a physician to receive full reimbursem*nt. That would be the best option.

I can help you research this further if you can provide me with the insurance payer names. Hope that helps.

Agree 100% with the previous post - changing the code to something other than what the documentation supports just to avoid a denial is not a compliant practice and I would not recommend doing this unless you can show something in writing such as a written policy or something in your contractual agreement with the payer that instructs you to bill this way.

I'd just add that if it is the case that your agreement with the payer allows for down-coding these visits, I would still advise against billing one code for the provider's credit and then changing it after the denial - that could be considered abuse of the claims system. As the previous poster states, you should bill correctly the first time. Your billing system should be able to be set up to track these by creating a 'dummy code' or a mapping that would allow the correct RVU to be recorded for the provider and the correct code to be submitted to the payer at the same time, or by some other method to allow the provider's credit to be calculated accurately. It's wasteful to both your practice and to the payer to be submitting claims that you know are going to be denied and require rework in being resubmitted.

avon4117 said:

medical decision making is what drives the code...so even if there is a comp hx, and comp exam, if the medical decision making is low...then the code is low.

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That's incorrect on a couple of counts - CPT guidelines for established patients are for the code level to meet 2 of 3 key components, or to be based on time if documentation supports it. CMS requires the level to meet medical necessity, but that's a different thing than MDM. Some practices do have internal guidelines to have MDM drive the code choice, but that is not a CMS or universally accepted guideline.

But that's a moot point here, because there's no reason a NP couldn't document high complexity MDM.

thomas7331 said:

That's incorrect on a couple of counts - CPT guidelines for established patients are for the code level to meet 2 of 3 key components, or to be based on time if documentation supports it. CMS requires the level to meet medical necessity, but that's a different thing than MDM. Some practices do have internal guidelines to have MDM drive the code choice, but that is not a CMS or universally accepted guideline.

But that's a moot point here, because there's no reason a NP couldn't document high complexity MDM.

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im speaking on new patient visits..which requires all 3 components....