How to Handle an Incorrect Diagnosis Code on a Claim
Published on Tue May 01, 2001
If a coder enters an incorrect diagnosis code and the claim is rejected as a result, the urologist and the coder must decide how to handle the situation. Urologists should not change the diagnosis on a claim for payment after they have filed it. However, sometimes the coder notices the error when the explanation of benefits (EOB) comes back. The claim may be paid in spite of the error, or denied because of it.
If the payer denied the claim because of the diagnosis, but the diagnosis was correct, do not refile, and do not change any of your documentation. A diagnosis should not be changed for the purpose of getting payment, says Michael A. Ferragamo, MD, clinical assistant professor of urology at the State University of New York, Stonybrook. Always use the proper diagnosis and correlate it with the procedure.
Bladder Scans for Residual Urine
Not all diagnoses that apply to a patient correlate with the procedure you perform. For example, if you perform a bladder sonogram for residual urine on a Medicare patient (G0050), and use the benign prostatic hyperplasia (BPH) diagnosis code (600.0) because you see an enlarged prostate on the scan, the payer will not reimburse because the diagnosis does not support the procedure. Rather, you should code 788.21 (incomplete bladder emptying), which supports a scan done primarily to look at residual urine, or 788.20 (retention of urine, unspecified) if you performed the scan due to retention. You should note that the prostate is enlarged on your office notes, but the billing should be based on the reason for the scan, Ferragamo says.
If a claim is denied for G0050 because you have entered the wrong diagnosis, you should not necessarily refile, especially if little money is involved. But use the opportunity to educate your staff about proper diagnosis coding.
Bladder Scans for Lesions
Its easy to see why a coder could get confused a patient actually does have a certain diagnosis, but has another diagnosis as well. Which do you use for the CPT codes? Use the one that is the most appropriate. That should also be the diagnosis that gets the code paid (although some carriers allow more diagnosis codes for a certain procedure than other carriers).
For example, the urologist performs 76775 (echography, retroperitoneal [e.g., renal, aorta, nodes], B-scan and/or real time with image documentation; limited) to look at hypertrophy of the bladder wall (596.8). He or she may notice a bladder tumor during the sonogram. But even if the physician sees one, many carriers wont pay [...]
