Wiki Excludes 1 vs Diagnosis Pointers

Messages
2
Location
Rosemead, CA
Best answers
0
Hi all, I was hoping to get some guidance on this issue that a provider had brought to my company's attention.

They are an Ophthalmology provider who has been billing excludes 1 codes along with other diagnoses in the same claim header. For example, they are reporting H16.223 (Keratoconjunctivitis not specified as Sjogren's bilateral, H11.041 (Peripheral pterygium right eye), and E11.3213 (T2DM Mild NPDR without Macula edema bilateral). The CPT codes reported are: 99203 and 92134-50. The E&M code has the diagnosis pointer for all 3 diagnosis, while the procedure (92134) has the diagnosis pointer on the T2D diagnosis. However, our vendor has denied the entire claim due to Excludes 1 note between the diagnosis code H16.223 and H11.041. The provider are saying that the procedure code should be paid as the exclude 1 diagnoses were not related to the procedure, and my management is saying the same thing (they are not coders btw). However, if I recall, the excludes 1 notes affects the entire claim not just by claim line.

I have the billing and coding guidelines inside and out, and there is nothing indicating diagnosis pointers relations with excludes 1 notes. I was wondering to get some insight from other individuals to see if they have experience this. Thanks in advance!
 
Hi all, I was hoping to get some guidance on this issue that a provider had brought to my company's attention.

They are an Ophthalmology provider who has been billing excludes 1 codes along with other diagnoses in the same claim header. For example, they are reporting H16.223 (Keratoconjunctivitis not specified as Sjogren's bilateral, H11.041 (Peripheral pterygium right eye), and E11.3213 (T2DM Mild NPDR without Macula edema bilateral). The CPT codes reported are: 99203 and 92134-50. The E&M code has the diagnosis pointer for all 3 diagnosis, while the procedure (92134) has the diagnosis pointer on the T2D diagnosis. However, our vendor has denied the entire claim due to Excludes 1 note between the diagnosis code H16.223 and H11.041. The provider are saying that the procedure code should be paid as the exclude 1 diagnoses were not related to the procedure, and my management is saying the same thing (they are not coders btw). However, if I recall, the excludes 1 notes affects the entire claim not just by claim line.

I have the billing and coding guidelines inside and out, and there is nothing indicating diagnosis pointers relations with excludes 1 notes. I was wondering to get some insight from other individuals to see if they have experience this. Thanks in advance!


The diagnosis codes with the exclusion are both pointing towards 99203, correct?

Most of the time, you're not going to see a line-by-line denial for diagnosis issues. It's not something you'll find in the ICD-10 guidelines - it's just part of how the payer(s) define a clean claim.

The best practice is to send a clean, error-free claim out the first time.
 
The diagnosis codes with the exclusion are both pointing towards 99203, correct?

Most of the time, you're not going to see a line-by-line denial for diagnosis issues. It's not something you'll find in the ICD-10 guidelines - it's just part of how the payer(s) define a clean claim.

The best practice is to send a clean, error-free claim out the first time.
Yes, the diagnosis codes with the exclusions are pointing towards 99203. That code was denied for the exclusion.
That's what I thought for the line by line. I explained that a clean claim would be the best practice; however, my management is saying that not all providers can do that.
 
Top