# Re-coding for denials



## malinusky (Feb 1, 2011)

Hello All,

I have a situation in our practice relating to denials based on diagnosis. Many of you have surely experienced upset patients calling stating their bill wasn't paid because, according to the insurance company, the wrong code was used. Our compliance department has advised us that changing the diagnosis or LOS to a denied claim either to obtain payment or avoid pt responsibility, i.e., deductibles, co-insurance, is fraud. Does anyone have experience with this and/or documentation,from Medicare/CMS to support this policy? 

Any direction would be greatly appreciated.

Thank You.


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## mitchellde (Feb 1, 2011)

I am not sure what you are looking for but anytime you change a dx to satisfy a payment decision then you run the risk of fraud.  You code from the documentation not for a payment decision.  The diagnosis is the patient's and the provider documents the diagnosis this then drives the diagnosis code, not payment nor a patient copay issue.  to do anything else contitues a flase claim and therefore fraud.


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## PURNIMA (Feb 2, 2011)

Hi,

I completely agree with Mitchell, however we can change the Diagnosis if that condition is documented in the medical record. 

Say for e.g - patient comes in with non cardiac  chest pain and the final Dx is  Gastritis. With all complete cardiac workup, MD woudl finally diagnose it is gastritis and for the workup we would code with 99285 (If it is a ER Visit) linking Gastritis code - 535.XX

Insurance companies will surely deny 99285, stating it is not medically necessary, in such situations we may bill with 786.5X as primary Dx and then code 535.XX. So this would solve the purpose of correct coding and a clean claim.

Hope this answers your question and this is just an example...

Thanks,

Purnima S, CPC






malinusky said:


> Hello All,
> 
> I have a situation in our practice relating to denials based on diagnosis. Many of you have surely experienced upset patients calling stating their bill wasn't paid because, according to the insurance company, the wrong code was used. Our compliance department has advised us that changing the diagnosis or LOS to a denied claim either to obtain payment or avoid pt responsibility, i.e., deductibles, co-insurance, is fraud. Does anyone have experience with this and/or documentation,from Medicare/CMS to support this policy?
> 
> ...


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## mitchellde (Feb 2, 2011)

PURNIMA said:


> Hi,
> 
> I completely agree with Mitchell, however we can change the Diagnosis if that condition is documented in the medical record.
> 
> ...



I disagree, you cannot use the 786.5x code since it is the symptom which has been explained with the gastritis dx.  Coding guidelines specifically state that you do not code the symptoms associated with the definotive dx.


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## MMAYCOCK (Feb 2, 2011)

malinusky said:


> Hello All,
> 
> I have a situation in our practice relating to denials based on diagnosis. Many of you have surely experienced upset patients calling stating their bill wasn't paid because, according to the insurance company, the wrong code was used. Our compliance department has advised us that changing the diagnosis or LOS to a denied claim either to obtain payment or avoid pt responsibility, i.e., deductibles, co-insurance, is fraud. Does anyone have experience with this and/or documentation,from Medicare/CMS to support this policy?
> 
> ...


I disagree with Michelle: You are not actually "changing the diagnosis. You are citing the reasons for the tests and the link to their medical necessity. Here is documentation: 
*The Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) mandates that patients must be evaluated to determine whether an emergency medical condition exists, she says. When a patient presents with chest pain, an evaluation to determine whether an emergency condition exists might well include a cardiac workup based on the nature of the patients presenting symptoms. As you can see, coders are caught in the middle.

Note: Federal legislation has been proposed that would require all health care insurers to reimburse ED claims based on presenting symptoms rather than final diagnoses, but this bill has never been passed. However, federal law does require Medicare to pay ED claims based on presenting signs and symptoms, and some states have passed similar legislation for payers in their states. ED coders should check to see whether their state legislature has passed such a law.

Code Should Indicate Reason for Encounter

According to the guidelines, the diagnosis code chosen should reflect the diagnosis or problem that is the chief reason for the encounter, Edelberg emphasizes. In the ED, the chief reason for the encounter must relate to the physicians consideration of the patients signs, symptoms, and/or complaints, particularly if they indicate a potentially higher level of acuity than the final diagnosis.

To support her interpretation, Edelberg points out that Medicare policy on medical necessity for services and procedures indicates that ICD-9 codes should indicate the reason that the service or procedure was performed.
Furthermore, in keeping with the federal law, the Medicare carrier manual specifically states that determination of a medical emergency should be prospectively on the presenting signs and symptoms, not retrosectively on the final diagnosis, she states.

It is clear that they intend the diagnosis reported for a test or procedure to represent the condition known to the physician at the time the service is performed, not a condition that may be confirmed several hours later, she adds.

The best advice to offer is for ED management and coding staff to consider the different interpretations of the diagnosis coding guidelines, go over the available guidelines themselves (see box at left), and examine their payers policies and the laws in their state to determine a method for accurately and appropriate reporting their emergency department encounters.*


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