Wiki Office visit getting denial with incomplete/invalid diagnosis

[chisomnwaneri]

Hi Please, could anyone give me a hint why I keep getting denial on office visits with invalid/incomplete diagnosis reason and my diagnosis are 1st diag: R11.11, 2nd diag: R19.7, and 3rd: R21. Could it be the arrangement

 

[TThivierge]

Hi Chisomnwaneri
All these are unspecified dx codes and dx R21 needs 4 digits. Is your provider not giving you a exact definitive dx ? If not you have to use the symptoms R block dx codes. Also keep in mind most dx codes a have another medical term in section of ICD10 manual that deals with differ specialty. You know gastro health is in section of disease manual starts with K. Instead of R19.7 you could use dx K59.1, or K58.O but the provider needs to give you detailed diagnosis codes in his or her documentation to match these dx. You should not have to guess. However if the medical record says these R codes......you cannot change the claim now. Dx R19.7 and R11.11 are unspecified some payers do not want to reimburse for this they feel a more definitive dx should be used. Is a better diagnosis listed in medical documentation ? Again if provider does not document a detailed dx code ; you are stuck using unspec. dx codes. Payers denial be the provider s fault. Keep in mind the inpt. setting can use R codes. Outpatient setting the payers do not like use of unspecified dx codes, however sometimes must be used.

Well I hope helped you a tiny bit.
Lady T

 

[csperoni]

Hi Chisomnwaneri
All these are unspecified dx codes and dx R21 needs 4 digits. Is your provider not giving you a exact definitive dx ? If not you have to use the symptoms R block dx codes. Also keep in mind most dx codes a have another medical term in section of ICD10 manual that deals with differ specialty. You know gastro health is in section of disease manual starts with K. Instead of R19.7 you could use dx K59.1, or K58.O but the provider needs to give you detailed diagnosis codes in his or her documentation to match these dx. You should not have to guess. However if the medical record says these R codes......you cannot change the claim now. Dx R19.7 and R11.11 are unspecified some payers do not want to reimburse for this they feel a more definitive dx should be used. Is a better diagnosis listed in medical documentation ? Again if provider does not document a detailed dx code ; you are stuck using unspec. dx codes. Payers denial be the provider s fault. Keep in mind the inpt. setting can use R codes. Outpatient setting the payers do not like use of unspecified dx codes, however sometimes must be used.

Well I hope helped you a tiny bit.
Lady T

I don't see where R21 needs a 4th digit. That's been the code for rash NOS since ICD10 started and is still valid in my 2023 book.
While a more specific diagnosis might help the situation, I honestly see no reason why these diagnoses (in any order) should be an issue. I did not see any excludes1 or excludes2 notes for them. IF the note currently indicates a more specific diagnosis (not suspected, consistent with, etc), then go ahead and use that. Otherwise, I would be going back to the carrier for a more definitive rejection reason.
For example, K59.1 for functional diarrhea instead of R19.7 diarrhea, unspecified is unusual outside of GI as functional diarrhea is chronic and/or recurrent.
While I don't support this, I have seen carriers that will deny or pend level 4 or level 5 visits unless the diagnosis code is on their "approved level 4/level 5 list." That scenario does not account for multiple lower level problems that in aggregate create a more complex visit.
Bottom line - I would contact the carrier. If no one could give me a better explanation than "incomplete/invalid diagnosis", I would submit an appeal letter with the visit note explaining how the coding is all correct, complete and valid.
Good luck!

 

[amyjph]

Agree, R21 doesn't need a 4th digit.
What office visit code is it linked to. Were there any other procedures or services done? Are signs/symptoms the only diagnoses that could be assigned from the documentation?

 

[TThivierge]

Hi Everyone
I checked again in ICD10 manual in which the correct dx R21 has no 4th digit. I was glancing at R20 dx code which has a 4th digit. Anyway I am glad we work as team to help everyone.
Lady T