Wiki Can a Provider remove a diagnosis code after receiving a denial for a visit?

[izsaba16]

I handle billing for a small Physical Therapy office. We've been seeing a patient since January of this year, and all their visits have been paid without any issues. However, on April 12th, we received a denial for their visit in late March, citing the reason code "The diagnosis is not consistent with the procedure." Surprisingly, the diagnosis codes and procedure codes remained unchanged. Upon reviewing the specific Explanation of Benefits (EOB), I noticed duplicate claims for that Date of Service (DOS). I suspected that might be the issue, and the error message was incorrect. I contacted a representative at the insurance company, and she agreed that it seemed like a mistake, as she could see all previous claims with identical codes were paid. She submitted it for review and mentioned I should hear back in about 15 days. However, it's been over a month, and I haven't received any updates.

Regrettably, I inadvertently submitted the patient's next visit without resolving the previous issue and received a denial for that visit today. (Yes, I acknowledge it's my fault, but I'm the sole person handling billing, denials, and processing and applying payments here, so I have a lot on my plate.)

I reached out to another representative at the insurance company for clarification on the issue. This time, I received more detailed information on the denial reason. It's based on the ICD-10-CM Excludes1 note guideline. Diagnosis codes H81.10 with R42 and R42 with H81.10 signify two conditions that shouldn't be reported together unless they're unrelated.

My question is, is the provider allowed to remove a diagnosis so we can receive payment for this? He won't be adding anything extra, and it won't change our reimbursement, so I don't believe this would be fraud. However, I'm unsure if it's allowed after it's already been submitted.

 

[rstroup]

Dizziness is a symptom of the condition your provider is treating. Per ICD-10 CM guidelines, "Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification."

Since there is an Excludes1 rule between R42 and H81.10, you would not code R42 since the provider has documented an established diagnosis.

--
Ryan Stroup, CPC

 

[sls314]

I handle billing for a small Physical Therapy office. We've been seeing a patient since January of this year, and all their visits have been paid without any issues. However, on April 12th, we received a denial for their visit in late March, citing the reason code "The diagnosis is not consistent with the procedure." Surprisingly, the diagnosis codes and procedure codes remained unchanged. Upon reviewing the specific Explanation of Benefits (EOB), I noticed duplicate claims for that Date of Service (DOS). I suspected that might be the issue, and the error message was incorrect. I contacted a representative at the insurance company, and she agreed that it seemed like a mistake, as she could see all previous claims with identical codes were paid. She submitted it for review and mentioned I should hear back in about 15 days. However, it's been over a month, and I haven't received any updates.

Regrettably, I inadvertently submitted the patient's next visit without resolving the previous issue and received a denial for that visit today. (Yes, I acknowledge it's my fault, but I'm the sole person handling billing, denials, and processing and applying payments here, so I have a lot on my plate.)

I reached out to another representative at the insurance company for clarification on the issue. This time, I received more detailed information on the denial reason. It's based on the ICD-10-CM Excludes1 note guideline. Diagnosis codes H81.10 with R42 and R42 with H81.10 signify two conditions that shouldn't be reported together unless they're unrelated.

My question is, is the provider allowed to remove a diagnosis so we can receive payment for this? He won't be adding anything extra, and it won't change our reimbursement, so I don't believe this would be fraud. However, I'm unsure if it's allowed after it's already been submitted.

Yes, you can remove the code. The first claim had an error - the codes shouldn't have been billed together in the first place.

You're just correcting the error. Not misrepresenting something to get paid.

Payers are getting more savvy in reviewing the coding guidelines and Excludes notes. Even if coding errors had slipped through on past claims, you may see future denials.

It may be helpful to have a coder and/or an edit checker review the diagnosis coding before claims are billed. This will save you time on the back end and minimize the denials that you have to work after the fact.

 

[csperoni]

Exactly!! You may certainly correct the coding if it was incorrectly coded. What you may not do is change the coding simply to receive payment if the original coding is correct.
And carriers are definitely catching onto the fact if they deny claims for Excludes1 diagnoses, they don't have to pay. One of my major carriers just implemented this in the past month or so.

 

[izsaba16]

Yes, you can remove the code. The first claim had an error - the codes shouldn't have been billed together in the first place.

You're just correcting the error. Not misrepresenting something to get paid.

Payers are getting more savvy in reviewing the coding guidelines and Excludes notes. Even if coding errors had slipped through on past claims, you may see future denials.

It may be helpful to have a coder and/or an edit checker review the diagnosis coding before claims are billed. This will save you time on the back end and minimize the denials that

Thank you! I really wish we had a dedicated coder or someone whose sole responsibility was to review claims before they were sent out. I've brought this up to our boss several times, but he doesn't see it as necessary. Unfortunately, most of the office staff here are juggling multiple roles they're not particularly knowledgeable about, which is causing more issues than necessary. (I do check codes, but I'm instructed not to spend too much time on it because I could be focusing on other tasks.)