When New Billing Codes Aren’t Recognized

In medical billing, code recognition is not the only reason for denial. If a claim containing a new code is denied, go through your medical billing claim and make sure it is absolutely accurate. Then you can probably narrow down the reason to simply a matter of the carrier not recognizing the CPT code.

When new medical billing codes are introduced there is a lag period that lets coders and payers get adjusted for that specific code. HIPPAA sets an effective date for all medical billing codes that states when companies must begin using the codes or accepting the new codes. It is illegal to deny claims for no recognition if the code effective date has passed.

There are instances in medical billing where code no recognition is acceptable. A payer can deny a claim with a new code if the effective date has not yet passed. If HIPAA released a code on January 1, but deemed the effective date to be March 1, then the payer doesn’t have to recognize the code until March 1.

Another big reason for denial is no coverage. If a payer rejects your new medical billing code, many times the rejection is due to no coverage. If you find that an insurance company is wrongfully denying your medical billing claims due to wrongful no recognition, there is something you can do. Since HIPAA makes this no recognition illegal, you can either complain directly to the carrier or opt to register a complaint against them.

These medical billing denials can easily slip through the cracks on both sides of billing. Both the physicians and carriers need to be on the alert for changes and making sure that their claims are reimbursed as fairly as possible or you’ll be losing valuable revenue for your practice.

View all Articles by: Kathryn E, CCS-P - Retired