Wiki ICD 10 code O36.813_ being denied due to unspecified (VT medicaid) but not unspecified per ICD 10 coding book

[arictara@gmail.com]

Been round and round with Medicaid VT(as we have many claims denied) as they have O36.8130 (per icd 10 book/guidelines 7th digits needs to be used)as unspecified and will deny..but then further more ICD 10 book indicates use 0 for 1 single gestations and multiple gestations where the fetus in unspecified. VT Medicaid is indicating this is an unspecified code and on their list as never to be used as primary. But the coders and myself are stating that we are following the ICD 10 Book/guidelines and using 0 for single gestations/not applicable to multiple gestations (also not listed as a unspecified code in book) also indicates in the highlighted caption...7th characters 1 through 9 are for cases of multiple gestations as well.

We have reached out and told to follow guidelines and resubmit with other code (specifying fetus)that is not on their unspecified list.
Also stated to do reconsiderations with codes submitted but have had calls and goes back to using those codes on the unspecified list.

What would be another option? Has anyone else seen/been through this? We have many claims denying using this code as primary dx.

 

[SharonCollachi]

We have reached out and told to follow guidelines and resubmit with other code (specifying fetus)that is not on their unspecified list.

What would be another option?

Well, another option would be to do what they're telling you to do. Insurance companies (and well, Medicaid isn't an insurance company, but whatever) have all kinds of policies and procedures that they shouldn't have, that are contradictory, whatever. Is it wrong to code something to get paid? Yes, but.... They're telling you what to do. Document that is their policy and they have instructed you to do that.