Gastroenterology Coding Alert

Question: We performed imaging for a patient who had a complaint of abdominal pain, and we received a denial for medical necessity from the insurance company since it turned out that nothing was wrong with the patient after all. Should we appeal?

Codify Subscriber

Answer: The answer depends on the payer policy for the particular imaging service you performed. If you check the coverage determination and discover that abdominal pain is not a covered diagnosis for that test, you may need to think further about whether the appeal is worth your time.

When considering whether another diagnosis is applicable, you should check the ICD-10 guidelines. The 2018 ICD-10 guidelines state: "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider." Sometimes, when accurate, using a code for abdominal tenderness R10.819 (Abdominal tenderness, unspecified site) rather than for a less specific abdominal pain code will pass muster with the payer.

In this example, a definitive diagnosis has not been established, so you should not resubmit with a different diagnosis. If, after checking your local coverage determinations (LCDs) and confirming with the payer that the diagnosis code is not eligible for payment, you should speak with the clinician about whether the appeal is warranted, since the denial was based on lack of medical necessity.

If you do decide to appeal, you should state in your appeal justification that the patient presented for imaging due to abdominal pain, with the final diagnosis being inconclusive of any definitive disease. You may include information that explains how imaging is vital in identifying diseases and disorders of the abdomen. You should also consider including a handwritten note from the provider explaining the medical necessity behind the procedure, which should specify which potentially serious or life-threatening conditions were being considered to be ruled out.

Medicare defines medically necessary services as "healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine." Therefore, if you are able to justify the imaging service as a medically necessary component in treating and diagnosing the underlying cause of the patient's postnasal drip, you may be able to heighten your chances of getting the appeal overturned.  

If, on the other hand, the clinician does not believe that the documentation would support an appeal (for instance, if the documentation simply says "unspecified abdominal pain" with no further details), then you may not want to spend the time on the appeal.