Wiki State Medicaid Rejecting OBGYN claim for Dx codes

[carlystur]

I just got hired by an OBGYN in my area and have been asked to handle a project of Waystar/Payer Rejections.

Here's what was billed out on 3/13 DOS this year:

• 99214 with only Z34.81;
• 81025 with only Z32.01; and
• 81002 with only Z34.81

The Rejection Message on Waystar states: "AP0587 HP Condition History: <D573,K219,MRX2). Review the Medical Record for DOS; Validate the Dx codes are complete and accurate; Resubmit the claim to Earn COC Bonus Up to $300. Refer to the COC Guidelines for Details."

Any ideas?

 

[sls314]

I just got hired by an OBGYN in my area and have been asked to handle a project of Waystar/Payer Rejections.

Here's what was billed out on 3/13 DOS this year:

• 99214 with only Z34.81;
• 81025 with only Z32.01; and
• 81002 with only Z34.81

The Rejection Message on Waystar states: "AP0587 HP Condition History: <D573,K219,MRX2). Review the Medical Record for DOS; Validate the Dx codes are complete and accurate; Resubmit the claim to Earn COC Bonus Up to $300. Refer to the COC Guidelines for Details."

Any ideas?

Have you looked at the medical record for this visit? That's where I'd start. What happened on the visit?

Here are some avenues I'd explore to work the denial, based on the limited information I have and not being able to see the visit note:

Z31.81 has an Excludes1 note for Z32.0-




What state is this in? Medicaid varies from state to state. Is this managed Medicaid or traditional Medicaid?

When I google "COC bonus up to $300," I see results about Continuity of Care bonus for managing chronic conditions. Most of the results that I quickly saw are from Centene health plans - is this a managed Medicaid from Centene?

It looks like the patient has a history of some chronic conditions, based on the diagnoses given in your original post:

D57.3 - sickle cell
K21.9 - GERD

In the medical documentation for this visit, were either of these conditions managed or did they affect the episode of care? (I could see sickle cell being relevant during a pregnancy, but if your provider didn't address the diagnosis it shouldn't be added. Same for GERD.)

The MRX2 looks like it could be a state Medicaid specific or plan specific code, so it's hard for me to answer that without being able to search specific to the state. (It looks like in Washington Medicaid that code would equates to a Medicaid RX risk category, but it could mean different things in different states.)

 

[carlystur]

Thank you for responding. This patient has Peach State Health Plan in Georgia as their insurance, which a google search tells me is owned by Centene Corporation. When I search for Peach State Health Plan and MRX2, only information about Peach State shows up.

The note doesn't seem to say anything about the extra diagnoses of D57.3 or K21.9. It does say that a Pregnancy test happened, which was positive. It also says in the HPI that the patient went to the office due to a positive pregnancy test. The provider then performed a Pregnancy Test (81025), which came back positive, and a Urinalysis - Manual w/o Micro (81002). I'm thinking about removing Z34.81, but it seems that a full progress note was done with Chief Complaint, HPI, ROS, Exam, Lab results, Assessment and Treatment Plan. Should I remove Z32.01 instead, maybe?