Wiki Missing or Invalid Diagnosis

[lindam@caricures.com]

I am in Pennsylvania - we saw a patient that had Wellcare of Georgia (Medicaid). They have continually denied our claim. They aren't denying as being out of state but for Missing or invalid diagnosis.

She had abnormal findings on a PET scan, was referred for colonoscopy. I originally billed 45378 with the PT modifier (probably shouldn't have) with DX code Z12.11 and R93.89. Rejected as LCD - Missing or Invalid Diagnosis. Resubmitted without the PT modifier and only R93.3. Same rejection codes. When I search Medicare - do I search for PA or Georgia?

 

[LisaAlonso23]

The correct diagnosis would be R93.3 without the PT modifier, as this is not a screening due to the abnormal finding.

 

[lindam@caricures.com]

I tried that. Unfortunately it didn't work either.

 

[nickelclaw]

they shouldn't have there is no edit that R93.3 primary dx only and whatever finding there were on the colonoscopy with 45378.

 

[lindam@caricures.com]

they shouldn't have there is no edit that R93.3 primary dx only and whatever finding there were on the colonoscopy with 45378.

that's my thinking too, but I doesn't seem to be theirs

 

[TThivierge]

Linda,
What was the abnormality......polyps, ulcers, constipation, K59 or R19 ,bleeding K92 from lab report? Did pt. have other digestive symptoms documented? Maybe doc needs to give you that to bill payer first. The payer wants more data IF documented properly. Then add last dx code Z12.11.
I hope helped you in some manner
Lady T

 

[swisssmizz]

Any signs or symptoms ie. abnormal PET finding is not considered a screening (https://med.noridianmedicare.com/we...colonoscopies-versus-diagnostic-colonoscopies) so diagnosis Z12.11 is not appropriate. With Wellcare, at least in Washington state, they do a lot of invalid denials so if they are denying 45378 with dx R93.3 and no modifiers you will need to submit a provider dispute. You can get the form from the website.