This procedure is not paid separately.
CO — Contractual obligation — the provider absorbs it and cannot bill the patient.
So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
Usually recoverable. Appeal it. The money is usually there.
In the order we see it.
The procedure is not separately payable under the payer's policy.
An NCCI edit makes it inclusive to another service on the claim.
Check NCCI edits. If a modifier is supported by the documentation, correct and resubmit.
The documentation, not the argument.
Documentation supporting a modifier, where the policy allows one.
The common mistake. Check the NCCI edit before appealing. If the pair is a hard edit, no modifier will change the outcome.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound