Why is medical service code 99397 not paid for?

There are several reasons why medical service code 99397 may not be paid for. Some of the most common reasons include:

* The service was not medically necessary. Code 99397 is for a prolonged office visit that typically lasts more than 60 minutes. To be considered medically necessary, the visit must be for a complex medical condition that requires a detailed evaluation and discussion of treatment options. If the visit was for a routine checkup or a simple medical problem, it may not be considered medically necessary and the claim may be denied.

* The documentation does not support the code. When billing for code 99397, the provider must submit documentation that clearly describes the nature of the visit and the complexity of the medical decision-making involved. This documentation should include a detailed history of the patient's symptoms, a physical examination, laboratory and imaging studies, and a discussion of the treatment options that were considered. If the documentation is not sufficiently detailed, the claim may be denied.

* The patient's insurance does not cover the service. Some insurance plans may not cover code 99397, or they may only cover it under certain circumstances. For example, some plans may only cover code 99397 if the patient is seen by a specialist or if the visit is for a specific type of medical condition. It is important to verify the patient's insurance coverage before submitting a claim for code 99397.

* The claim was submitted incorrectly. There are a number of technical requirements that must be met when submitting a claim for code 99397. For example, the claim must be submitted using the correct CPT code, the appropriate modifiers, and the correct diagnosis codes. If the claim is submitted incorrectly, it may be denied.

If you have received a denial for a claim for code 99397, it is important to review the explanation of benefits (EOB) carefully to understand the reason for the denial. You may also want to contact your insurance company to discuss the denial and see if there is anything you can do to appeal the decision.