Wiki F52.21 vs N52.9 - Help!

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Sdrivera

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One of our urology providers saw a patient for erectile dysfunction and used F52.21 as the primary diagnosis. BCBSTX-HMO denied the claim due to "not covered when performed for the reported diagnosis." Is there a BCBSTX policy that states you can't use this as a primary diagnosis code for an office visit? It was billed with 99214 along with ICD-10 code E29.1.

Would N52.9 or another N52- code be more accurate in this instance? The note does not contain any psychological reasoning. Patient was on Cialis for many years which quit working...switched to Sildenafil...still not fully working.

I'm thinking a N52- code is more appropriate, but would like to see if anyone is aware of any BCBSTX guidelines in regards to this.

TIA!
 
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The problem isn't that it's not allowable for the primary diagnosis....it's the fact that the insurance company doesn't pay for coverage for erectile dysfunction. If that's the diagnosis, that's what you need to use. You should not re-code for payment.
 
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Sdrivera said:
One of our urology providers saw a patient for erectile dysfunction and used F52.21 as the primary diagnosis. BCBSTX-HMO denied the claim due to "not covered when performed for the reported diagnosis." Is there a BCBSTX policy that states you can't use this as a primary diagnosis code for an office visit? It was billed with 99214 along with ICD-10 code E29.1.

Would N52.9 or another N52- code be more accurate in this instance? The note does not contain any psychological reasoning. Patient was on Cialis for many years which quit working...switched to Sildenafil...still not fully working.

I'm thinking a N52- code is more appropriate, but would like to see if anyone is aware of any BCBSTX guidelines in regards to this.

TIA!
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What does the note specifically say? Look to the alphabetic index for your answer.

In the ICD 10 alphabetic index, the default code for Erectile Dysfunction is N52.9. (Dysfunction - sexual - male - erectile: N52.9)

To get to F52.21 from the Alphabetic Index, you'd need to look under Dysfunction - sexual - male - erectile - psychogenic: F52.21

Since you said that the note doesn't state anything about it being psychological, it sounds like your physician assigned the wrong code; You can correct a code that was misused.

(As Pam said above, you wouldn't change a correctly assigned code just to get payment. However, it sounds like the code wasn't correctly assigned in this case. That's something you can correct.)

I would also recommend educating your physician on the distinction between N52.9 and F52.21 to make sure he chooses the correct code for future payments.

If he's not intending to diagnose the patient with psychogenic erectile dysfunction, he doesn't want to use that F code. F codes can often cause denials on medical policies, especially if the patient has a carve-out carrier for behavioral benefits.

(Of course, use the F52.21 code if the intent is to diagnose the patient with psychogenic erectile dysfunction. The coding needs to accurately reflect the patient's diagnosis.)
 
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