Wiki Horizon denials for dx mismatched

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klamond

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We have been receiving numerous denials from Horizon for established pt E&M codes such as 99214 for "diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting". From what I can see the dx codes always have the correct suffix, laterality is specific, there are no excludes 1 notes between them. An example would be S83.272A with M17.0 billed for CPT 99214. I have researched the official guidelines on CMS but can't find anything regarding this issue. What am I missing? Any input would be greatly appreciated.
 
You are billing for an injury to the knee as well as bilateral osteoarthritis of the knee.. so the payer may be confused as to the nature of the encounter. If there is an injury and this is the visit for initial treatment of that injury, do you also have the external cause codes to go with it? It is confusing to see these codes used together for the same encounter. If these are separate diagnosis that do exist at the same time an external cause can go a long way to explaining. If the osteoarthritis was not treated at the same time as an acute injury then I would not list it. If they are distinct conditions and both are treated at the same encounter you can send the notes to appeal.
 
mitchellde said:
You are billing for an injury to the knee as well as bilateral osteoarthritis of the knee.. so the payer may be confused as to the nature of the encounter. If there is an injury and this is the visit for initial treatment of that injury, do you also have the external cause codes to go with it? It is confusing to see these codes used together for the same encounter. If these are separate diagnosis that do exist at the same time an external cause can go a long way to explaining. If the osteoarthritis was not treated at the same time as an acute injury then I would not list it. If they are distinct conditions and both are treated at the same encounter you can send the notes to appeal.
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Thank you! I will try adding them to one of the corrected claims and see if that's what they are looking for. We used to use them but our clearinghouse edits for Horizon used to kick the claims out before they even got to Horizon. I appreciate your input.
 
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