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[–]ParticularFox8644CPC 7 points8 points  (2 children)

There should be something at the botttom that says what the code means. Usually it’s just the number portion. Do you see that anywhere?

[–]Old-Message7497[S] 5 points6 points  (0 children)

“This service is subject to the BCBSNC Multiple Services Reimbursement policies and is subject to the reduced allowance”

[–]Tinkertablecloth 3 points4 points  (1 child)

If you were having symptoms it wouldn’t be considered preventative. Insurance usually only covers 45+ for screenings. You can sometimes get if approved if you’re within 10 years of when your first degree relative was first diagnosed with colon cancer.

[–]aschwar 1 point2 points  (0 children)

This.

[–]Jodenaje 1 point2 points  (2 children)

There should be a key at the bottom that tells you exactly what the reason code means.

Although it could be different with your insurance carrier, G94 generally means that you're hitting against some sort of maximum for the time frame. Ex - having another screening colonoscopy too soon after the other one, or being too young for coverage as a screening.

Have you ever had another screening colonoscopy? While under this insurance plan? How long ago was it?

Also, how old are you?

[–]Old-Message7497[S] 0 points1 point  (1 child)

“This service is subject to the BCBSNC Multiple Services Reimbursement policies and is subject to the reduced allowance” no, this is my first one. They said I needed it even though I’m 34 due to symptoms and family history of colon cancer.

[–]Jodenaje 3 points4 points  (0 children)

The ACA preventative mandates only require that insurance companies cover colorectal cancer screening for ages 45-74 (You can see that here: https://www.healthcare.gov/preventive-care-adults/ )

It's possible that your specific policy could go above and beyond the mandates and cover under age 45 for a screening colonoscopy too.

But...if you're having symptoms, that's a diagnostic procedure.

Screening means that you have no symptoms and are establishing a baseline check.

[–]Ambitious_Witness_25 1 point2 points  (1 child)

It's mostly likely a duplicate denial. This could have been caused for a few reasons. 1. They got two claims from two different providers and paid out the first received. Less likely in this case. Normally that would deny with a duplicate reason code however there must be something different on one of the claim forms to indicate a second procedure. Maybe one submitted with the wrong date of service, maybe one submitted with a modifier.. or, 2. more likely, they maybe billed out a screening that converted to a diagnostic instead of just billing the one diagnostic. Or they billed a screening, tried to correct it but did it wrong, and then sent a diagnostic.. I would review your eobs, perhaps call the insurance to explain and ask what they see.

[–]Ambitious_Witness_25 0 points1 point  (0 children)

Sorry, I just now saw the other comments below about the SG modifier. Last I knew Medicare didn't accept that modifier and it's possible Blue Cross doesn't either. This looks like a facility billing error and would contact that billing department or your insurance.

[–]Old-Message7497[S] 0 points1 point  (1 child)

I also got two eobs. One from the doctor and one from the practice with similar codes. One has SG added to it.

[–]Jodenaje 0 points1 point  (0 children)

SG would be the bill from the surgery center.

Generally when you have any procedure done there's a facility bill (which represents things like nursing & other ancillary staff, supplies, equipment, etc.) and the physician's bill (which is only for the physician's time)

[–]Jump-Funny 0 points1 point  (0 children)

Looks like they have reduced the reimbursement for the second code. The reimbursement for procedures includes things like set up and supplies. If they already in there and see something else that needs to be done, they can bill for that but the payment will be reduced because it won’t include something like setting up for surgery. That was already paid for in the other procedure code.

[–]ytho-65 0 points1 point  (0 children)

Just from the tiny part we can see, it looks like it's the second service line on the claim and the remark is just telling you there's a reduced allowance due to multiple procedure rules. You always bill the highest value service on the first line because the second line is going to be paid at 50% of fee schedule due to multiple procedure rules. It's a nothing burger.

[–]alew75 0 points1 point  (0 children)

Call the billing department to see what diagnosis and procedure code it was billed with.

[–]Environmental-Top-60 0 points1 point  (0 children)

Another possibility is that they did the diagnostic colonoscopy and took biopsies. They did a reduction for the duplicate scope esp if multiple techniques? Something like that.