Wiki Should self pay diagnosis codes be submitted to insurance?

[Mary.e.barnes82@gmail.com]

Good morning everyone, I'm hoping you good people can assist with a coding problem. My manager (non-coder), a coding colleague and I disagree with how to handle a particular issue.

I work for an urgent care clinic that provides self pay services such as children's sports physicals (Z02.5), form completion services (Z02.89). There are instances where the patient is seen for an additional service such as a flu vaccine or sick visit which is submitted to their insurance. The issue lies with whether the self pay dx code(s) should be included on the claim along with the dx codes that are being submitted to insurance.

My manager and colleague state that we have to include the dx code(s) for the self pay services on the claim being submitted to insurance as the patient had the service performed, not doing so would be fraud. However, I stated that since the patient paid for the services out of pocket and the associated dx code(s) should not be submitted to insurance.

I know this was a lot (I'm sorry), but I need to guidance of my fellow coders as to who is correct. Thank you in advance.

 

[jkyles]

Hi there, I think submitting irrelevant diagnosis codes potentially creates a number of problems, including non-compliance with the HIPAA minimum necessary standard:

The HIPAA Privacy Rule requires a covered entity to make reasonable efforts to limit use, disclosure of, and requests for protected health information to the minimum necessary to accomplish the intended purpose. To allow covered entities the flexibility to address their unique circumstances, the Rule requires covered entities to make their own assessment of what protected health information is reasonably necessary for a particular purpose, given the characteristics of their business and workforce, and to implement policies and procedures accordingly.

 

[Mary.e.barnes82@gmail.com]

Hi there, I think submitting irrelevant diagnosis codes potentially creates a number of problems, including non-compliance with the HIPAA minimum necessary standard:

Thank you for taking the time to respond to me post. Would you suggest that a separate encounters and progress notes be created for both services?