snwhite0730
Contributor
Hello Fellow Coders,
I am hoping someone can help me to clarify some claims issues we are having. We are an Inpatient Acute Care Behavioral Health Hospital. To make a very long story short, we are getting a ton of denials from insurance because the admitting diagnosis that was given to obtain the prior authorization doesn't match the PDX at discharge.
When our patients are admitted they are seen by a MSW in the Intake department. They then 'diagnosis' the patient with MDD unspecified F33.9, Vascular Dementia F01.51 (they are NOT coders, so yes they are using F01.51 which isn't even a compete code and has a Code First Guideline to use the code!), SAD, unspecified F25.9 etc. Our UM department then takes this diagnosis and use them to obtain prior authorizations from the insurance carrier. Once they are seen by and evaluated by the MD's the diagnosis change, of course. Very rarely does the diagnosis given by the Provider ever match what the MSW's are giving the patients at intake. Thus, when we submit claims, the insurance comes back and basically says that the PA was obtained for a completely different diagnosis and are using that as a means to deny the claims.
The way I see it, UM should not be using any diagnosis given by the MSW as we are Inpatient care that is supposed to be directed by the doctors and not an outpatient clinic where MSW's are the clinical staff treating the patient and should not be 'diagnosing' the patient during intake, rather they should use the symptoms ( suicidal ideation, self-harm, danger to others, VH, AH, psychosis, etc. ) that lead the patient to come to the facility. I have said on more than one occasion that they shouldn't even be using diagnosis codes at all. My supervisor, when I brought this to their attention told me in the state of Arizona (where we are) MSW's are allowed to give an admitting diagnosis. I have not been able to find this documented anywhere. In my opinion, a lot of this would go away if the UR department would use the diagnosis given by the MDs on the psych eval which is completed 24 hours after they get to the hospital.
The place I work doesn't understand what us coders do and really don't value our opinions and we are lumped in with health information, so my getting them to change procedure is highly unlikely; but for my own knowledge and as far as I am concerned, ethics, demand I confirm if the practice of the MSW's giving diagnosis without first consulting the MD's is just plain wrong.
Any links, prior experience or knowledge is greatly appreciated. Thank you!!
I am hoping someone can help me to clarify some claims issues we are having. We are an Inpatient Acute Care Behavioral Health Hospital. To make a very long story short, we are getting a ton of denials from insurance because the admitting diagnosis that was given to obtain the prior authorization doesn't match the PDX at discharge.
When our patients are admitted they are seen by a MSW in the Intake department. They then 'diagnosis' the patient with MDD unspecified F33.9, Vascular Dementia F01.51 (they are NOT coders, so yes they are using F01.51 which isn't even a compete code and has a Code First Guideline to use the code!), SAD, unspecified F25.9 etc. Our UM department then takes this diagnosis and use them to obtain prior authorizations from the insurance carrier. Once they are seen by and evaluated by the MD's the diagnosis change, of course. Very rarely does the diagnosis given by the Provider ever match what the MSW's are giving the patients at intake. Thus, when we submit claims, the insurance comes back and basically says that the PA was obtained for a completely different diagnosis and are using that as a means to deny the claims.
The way I see it, UM should not be using any diagnosis given by the MSW as we are Inpatient care that is supposed to be directed by the doctors and not an outpatient clinic where MSW's are the clinical staff treating the patient and should not be 'diagnosing' the patient during intake, rather they should use the symptoms ( suicidal ideation, self-harm, danger to others, VH, AH, psychosis, etc. ) that lead the patient to come to the facility. I have said on more than one occasion that they shouldn't even be using diagnosis codes at all. My supervisor, when I brought this to their attention told me in the state of Arizona (where we are) MSW's are allowed to give an admitting diagnosis. I have not been able to find this documented anywhere. In my opinion, a lot of this would go away if the UR department would use the diagnosis given by the MDs on the psych eval which is completed 24 hours after they get to the hospital.
The place I work doesn't understand what us coders do and really don't value our opinions and we are lumped in with health information, so my getting them to change procedure is highly unlikely; but for my own knowledge and as far as I am concerned, ethics, demand I confirm if the practice of the MSW's giving diagnosis without first consulting the MD's is just plain wrong.
Any links, prior experience or knowledge is greatly appreciated. Thank you!!