Wiki trying to find out why facility claim got paid but not the professional fee

[rpayne151]

I am new to coding and am working on a denied claim that the facility side was paid but not for the professional claim. I reworked the claim and took out the R codes since they are to be excluding when using K44.9 for the procedure code. I also coded a K31.1, K22.2, and K20.0 for an EGD procedure that was performed with biopsies and a dilation and took out the symptoms that were explained upon completing the procedure. My question is should the ICD 10 codes not be the same for both claims? The facility claim got paid with the R codes and symptom included??? Trying to figure out why the professional fee got denied. Thanks for any input.

 

[thomas7331]

I am new to coding and am working on a denied claim that the facility side was paid but not for the professional claim. I reworked the claim and took out the R codes since they are to be excluding when using K44.9 for the procedure code. I also coded a K31.1, K22.2, and K20.0 for an EGD procedure that was performed with biopsies and a dilation and took out the symptoms that were explained upon completing the procedure. My question is should the ICD 10 codes not be the same for both claims? The facility claim got paid with the R codes and symptom included??? Trying to figure out why the professional fee got denied. Thanks for any input.

What did the payer give as the reason or the denial? There are a lot of reason for denying a claim and most have nothing to do with the ICD-10 codes. It may not be a coding issue at all.

In theory, yes, the facility claim and physician claim should have the same codes since both are being taken from the same medical record. But different coders may interpret things differently or may have different internal organizational guidelines that they're following, so the end result may be slightly different at times.

 

[rpayne151]

it is saying payment code wd- diagnosis code incorrectly coded per ICD10 manual. the procedure code used was 43248 and 43239 with modifier 59 with the previous mentioned ICD10 codes. That is why I resubmitted it with taking out the R codes. Then I realized the facility got paid with all the original symptom codes left in. So, was unsure as to why? Thank you for responding.

 

[thomas7331]

it is saying payment code wd- diagnosis code incorrectly coded per ICD10 manual. the procedure code used was 43248 and 43239 with modifier 59 with the previous mentioned ICD10 codes. That is why I resubmitted it with taking out the R codes. Then I realized the facility got paid with all the original symptom codes left in. So, was unsure as to why? Thank you for responding.

I don't see a problem with the four ICD-10 codes you mentioned above, but I'd have to see the entire original claim to really understand what's going on. Usually this type of denial is triggered by an Excludes note that prohibits two diagnosis codes from being used together. The presence of R codes shouldn't cause a denial unless one of them happens to be causing an Excludes note conflict with another of your codes.