Certified Medical Assistant (CMA AAMA)Administrative: Billing, Coding and SchedulingMedium
A medical assistant is reviewing a claim denial for a patient's annual physical exam, which was coded with CPT 99395. The insurance company denied the claim, stating 'service not covered.' Which of the following is the most likely reason for this denial?
- AThe CPT code used was incorrect for an annual physical.
- BThe patient's deductible had not been met.
- CThe claim was submitted after the timely filing limit.
- DThe patient's insurance plan does not cover preventive services.
Show answer & explanationAnswer & explanation
Correct answer: D. The patient's insurance plan does not cover preventive services.
Insurance plans vary in their coverage. Some plans, especially older or basic ones, may not cover preventive services like annual physicals, leading to a 'service not covered' denial even if the coding is correct.
Why the other options are wrong
- A. CPT 99395 is the correct code for a periodic preventive medicine visit for an established patient aged 18-39, so the code itself is likely not the issue.
- B. A deductible not being met would typically result in the patient being responsible for the cost, not a 'service not covered' denial.
- C. A timely filing limit denial would explicitly state 'claim denied due to timely filing' or similar, not 'service not covered.'
Preventive Services Coverage
Insurance coverage for medical care aimed at preventing illness, such as annual physicals, screenings, and immunizations.
- Coverage varies significantly by insurance plan.
- Many plans, especially under the Affordable Care Act, cover preventive services without cost-sharing.
- Older or basic plans may not cover certain preventive services.
Memory trick: COVERAGE limits, CODING errors, or TIMELY filing can cause claim denials.