Wiki Medicare Advantage Plans and billable ICDs

[holbjm@hotmail.com]

I have a patient under 65 disabled with a Medicare Advantage Plan. She was referred to our Cardiology practice for cardiac OR clearance. Patient has hypertension and obesity. The Managed Care plan is denying the claim due to ICD not age appropriate. When I questioned the denial I was told a preventative CPT needed billed with it. Anyone else have this issue and/or solution? CPT billed was 99204 with 93000, primary ICD was Z01.810

 

[amyjph]

Were there any other diagnosis codes reported on the claim?

 

[holbjm@hotmail.com]

Yes, I10, E66.01 and Z68.54

 

[sls314]

Yes, I10, E66.01 and Z68.54

How old is the patient? Z68.54 could be the culprit - it's a pediatric BMI code.

That could be the reason why you're getting the rejection for the ICD-10 not appropriate for the patient's age.

 

[holbjm@hotmail.com]

How old is the patient? Z68.54 could be the culprit - it's a pediatric BMI code.

That could be the reason why you're getting the rejection for the ICD-10 not appropriate for the patient's age.

Thank you. I wasn't even looking at that code, I was focused on the primary. I believe that is the issue. Thanks again.