02/05/2024

Excellus-Denial for Invalid ICD-10 Codes Reported with 99203, 99212, 99213

I have three patients that Excellus is denying for invalid codes being reported with CPT codes 99203, 99212, and 99213 stating that the diagnosis codes that were on claims cannot be reported together due to ICD-10 CMS coding guidelines. None of of diagnosis overlap with each patient so it's not one or two specific diagnosis codes. Are they correct?

Denials from Excellus are valid, based on the claim editing guidelines that they are using to process claims. It can reject particular combinations of ICD-10 codes. The recommendation would be to remove one of the diagnosis codes in question and submit a replacement claim for processing. To date, there is no information from Excellus on what code combinations are not allowed based on specialty. These edits have been implemented with other Blue Cross carriers in the region, such as Horizon BC/BS, due to more stringent edits used to adjudicate claims in comparison to other payers like Medicare.