Learn the most common reasons BrainCheck claims are denied and how to resolve them quickly to keep your revenue cycle on track.
1. Medical Necessity & ICD-10 Codes
Why It Happens:
If the ICD-10 code doesn’t support the test or interpretation, the claim will be denied. Preventative or screening codes are not covered.
Solution:
Always select diagnosis codes that demonstrate medical necessity.
Avoid using preventive/screening ICD-10s.
Double-check the LCD (Local Coverage Determination) or payer-specific medical necessity list before submitting.
2. Missing Prior Authorization
Why It Happens:
Claims get denied if prior authorization wasn’t obtained before the service. Insurers won’t allow back-dated authorizations.
Solution:
Secure authorization before rendering the service.
If missed, adjust the claim or service and submit corrected information.
3. Incorrect Modifier Usage
Why It Happens:
Claims can be denied for modifier errors or bundling issues.
Solution:
Use -59 on 96138 and 96132 when billed with E&M codes.
Apply -25 to the E&M code when BrainCheck is billed with other procedures.
For telehealth, use 93 (audio-only) or 95 (audio+video).
If a denial seems incorrect, submit a reconsideration with notes.
4. Code Combinations & Frequency Limits
Why It Happens:
Certain CPT codes don’t mix, and some have frequency restrictions. For example, 99483 cannot be billed on the same day as an office visit or other certain codes, and it can only be billed once every 180 days.
Solution:
Keep a billing calendar to track code usage.
Confirm codes are allowed to be billed together.
Respect frequency limits to avoid automatic denials.
5. Documentation Gaps
Why It Happens:
Time-based codes like 96136, 96138, and 96132 require documented time. Missing documentation results in automatic denial.
Solution:
Document time spent on each service clearly.
Include non-face-to-face activities (as allowed by CMS) in your notes.
Ensure supporting clinical notes are attached to the claim.
Additional Tip
Use the Billing Audit Checklist and Guidelines for Submitting Claims (available in the Help Center) to review before submission. These tools help prevent denials and keep claims compliant.