This Comparative Analytics report shows the top 20 most commonly denied procedures nationally across many specialties in the outpaitent market. CPT code 99213 had the highest volume of unexpected denials, while 96372 had the least out of this top 20 list. The total weighted average denial rate is 10.6% across this list of procedures in the US. This list was developed from electronic remits during this time period 5/7/2012 to 8/13/2012.

Procedure

Procedure Description

Unexpected Denial Rate

10.6%

99213

Low Complexity office or other outpatient visit for the evaluation and management of an established patient

7.6%

36415

Collection of venous blood by venipuncture

12.4%

99214

Moderate Complexity office or other outpatient visit for the evaluation and management of an established patient

7.5%

E1390

Oxygen concentrator

16.2%

99000

Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory

42.2%

99232

Moderate complexity - Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components

10.5%

85025

Diagnostic Laboratory - BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC COUNT

8.8%

E0431

PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING

18.1%

A4253

BLOOD GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50 STRIPS

11.2%

80053

Diagnostic Laboratory - COMPREHEN METABOLIC PANEL

9.0%

99212

Minor Complexity office or other outpatient visit for the evaluation and management of an established patient

8.5%

A4259

Lancets per box

9.8%

97110

Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

9.3%

80061

Diagnostic Laboratory - LIPID PANEL

8.1%

99233

High complexity - Subsequent hospital care, per day, for the evaluation and management of a patient

10.6%

E0601

Cont airway pressure device

12.8%

36416

CAPILLARY BLOOD DRAW

43.5%

94760

MEASURE BLOOD OXYGEN LEVEL

65.7%

99203

Low complexity office or other outpatient visit for the evaluation and management of a new patient

9.4%

96372

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

10.0%

This Comparative Analytics report shows the top 5 reason codes for Ambulatory Healthcare Facilities from 5/7/2012 to 8/13/2012. This report is created from elecrtronic remittances in the outpatient market across the US spanning many different specialties at these facilities.

Reason Code

Code Description

18

Duplicate claim/service. This change effective 1/1/2013: Exact duplicate claim/service (Use with Group Code OA).

45

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).

16

Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

97

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information  REF), if present.

96

Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information  REF), if present.