Appendixes
CPT copyright 2017 American Medical Association. All rights reserved.
VII. Sample Denial Tracking Tool
Codes Paid When Submitted
as a Clean Claim
Payer
Name
Payer
Name
Payer
Name
Payer
Name
Payer
Name
Payer
Name
Payer
Name
Payer
Name
Example: 90460/90461;
90471/90472:
Immunization admin
codes
Yes
Example: 992__ with
preventive medicine visit
(9938_/9939_) on same
date of service
No
Example: Normal newborn
care or hospital visits/dis-
charges when billed with
circumcision
Example: 92551: Hearing
screen
No, adj
off
Key: Yes = paid; No = no payment, appealed; Varies = payment is specific to employer’s benefit plan;
No, adj off = billed, denied, NO APPEAL, based on contract, adjust off.
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