Top 10 Medicare Denials for CPT Codes: What Providers Need to Know

Navigating Medicare’s denial landscape can be challenging for healthcare providers, as denied claims lead to lost revenue and increased administrative costs. Understanding the most frequently denied CPT (Current Procedural Terminology) codes and the reasons behind these denials can help healthcare organizations improve reimbursement rates and avoid costly errors. Here’s an in-depth look at the top 10 Medicare-denied CPT codes, along with best practices for reducing these denials.

1. CPT 99214 - Established Patient Office Visit (Moderate Complexity)

• Common Denial Reasons: Documentation insufficiency, lack of medical necessity, and coding errors.
• Tips to Avoid Denial: Ensure that the complexity level matches the documentation. Include all necessary elements, such as patient history, exam, and medical decision-making, to support the coding level.

2. CPT 99396 - Preventive Medicine Visit (Established Patient, 40-64 Years)

• Common Denial Reasons: Medicare often denies this as “not medically necessary,” as it does not cover preventive services under certain plans.
• Tips to Avoid Denial: Confirm Medicare coverage eligibility and verify if the patient’s plan includes preventive services or if an Advance Beneficiary Notice (ABN) is required.

3. CPT 36415 - Collection of Venous Blood by Venipuncture

• Common Denial Reasons: Service duplication, medical necessity, and bundling issues.
• Tips to Avoid Denial: Confirm that the service is separately payable under the patient’s plan and avoid double-billing when venipuncture is performed with other services.

4. CPT 99203 - New Patient Office Visit (Low Complexity)

• Common Denial Reasons: Incomplete documentation, coding errors, and new patient criteria not met.
• Tips to Avoid Denial: Make sure all required documentation is included, and confirm the patient qualifies as “new” under Medicare guidelines (no professional services provided by the same provider within the last three years).

5. CPT 99308 - Subsequent Nursing Facility Care (Low Complexity)

• Common Denial Reasons: Missing medical necessity and documentation inadequacies.
• Tips to Avoid Denial: Properly document the patient’s condition, services rendered, and reasons for continued nursing facility care to demonstrate medical necessity.

6. CPT 97110 - Therapeutic Exercises (Per 15 Minutes)

• Common Denial Reasons: Lack of documentation to support skilled therapy, exceeding therapy limits, and bundling issues.
• Tips to Avoid Denial: Include detailed notes about therapy goals, progress, and the medical need for ongoing therapy sessions.

7. CPT 99233 - Subsequent Hospital Care (High Complexity)

• Common Denial Reasons: Documentation not supporting complexity, duplication with other codes, and lack of medical necessity.
• Tips to Avoid Denial: Ensure that documentation reflects the high complexity required for this code. Include all elements that substantiate the need for a high-complexity visit.

8. CPT 97010 - Application of a Modality to 1 or More Areas; Hot or Cold Packs

• Common Denial Reasons: Bundling with other services, and Medicare’s non-coverage policy on certain modalities.
• Tips to Avoid Denial: Review Medicare’s bundling policies to determine if the service is covered when provided alongside other therapy services.

9. CPT 80050 - General Health Panel

• Common Denial Reasons: Medicare often does not consider this medically necessary or denies it for exceeding frequency limits.
• Tips to Avoid Denial: Verify if specific components of the panel are covered individually rather than billing the panel as a whole, and confirm the medical necessity before billing.

10. CPT 85025 - Complete Blood Count (CBC) with Automated Differential

• Common Denial Reasons: Medical necessity and frequency limitations.
• Tips to Avoid Denial: Confirm Medicare’s coverage guidelines on frequency and ensure a documented medical reason that justifies ordering the test.

---

Key Takeaways for Reducing Medicare Denials

While the reasons for denial vary by code, there are general steps providers can take to minimize the risk:

• Prior Authorization and Coverage Checks: Verify whether the service is covered under the patient’s specific Medicare plan before providing it.
• Proper Documentation: Ensure that medical records comprehensively support the coding level and medical necessity for the service rendered.
• Staff Training: Educate billing and coding staff on Medicare’s policies, including frequent updates to covered services and CPT code guidelines.
• Advance Beneficiary Notices (ABNs): For services with unclear coverage, obtain ABNs from patients to ensure transparency and reduce the likelihood of unexpected denials.

Final Thoughts

By proactively addressing the most commonly denied CPT codes, healthcare providers can reduce administrative burdens, speed up reimbursement, and maintain financial stability. Addressing the underlying causes of denials—whether they involve coding accuracy, documentation, or policy awareness—is essential to a smooth and efficient revenue cycle.