Wiki Reason code M81

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lindam@caricures.com

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I have several claims that weren't paid by Amerihealth Caritas (PA Medicaid plan) with the reason code of M81. You are required to code to the highest level of specificity. And 16 Claim/service lacks information which is needed for adjudication. I am not sure what these mean. On one patient it is in regards to hospital visits and another in regards to a surgery. For the hospital visits - they paid for 1 out of the 4 days of hospitalization. any suggestions?
 
Common causes of reason code M81 are
1. The diagnosis provided is not specific enough, indicating that a more detailed diagnosis is needed to support the medical necessity of the service or procedure.
2. Use of general or unspecified code
3 The use of a code that is not consistent with the patient's age, gender, or the clinical information provided.

Review the patient's record and update the diagnosis codes using the most current ICD-10-CM codes that reflect the highest level of specificity. After updating the codes, resubmit the claim to the payer. Hope this helps!
 
sasikalav said:
Common causes of reason code M81 are
1. The diagnosis provided is not specific enough, indicating that a more detailed diagnosis is needed to support the medical necessity of the service or procedure.
2. Use of general or unspecified code
3 The use of a code that is not consistent with the patient's age, gender, or the clinical information provided.

Review the patient's record and update the diagnosis codes using the most current ICD-10-CM codes that reflect the highest level of specificity. After updating the codes, resubmit the claim to the payer. Hope this helps!
Click to expand...

Patient had a chronic anal fissure. I used ICD 10 code K60.1 which is the only code I can find for a chronic anal fissure. I'm not sure how much more specific I can get.
 
If no other ICD10 code was billed, please call the insurance company to explain that the ICD code was billed with the highest level of specificity. If they still refuse to reprocess, gather all the documentation needed to appeal the decision, if you want to push the claim for reimbursement.
 
Be sure to look at all of the diagnosis codes on your claim and re-check that they are supported by the documentation. As sasikalav says, if all codes reflect the highest level of specificity, you'll have to appeal with the payer.
 
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