Does it matter the order or placement of V58.11, versus the cancer diagnoses? We have some payers that reject our chemo claims when V58.11 is primary. It is a system issue, and they aren't able to match the drug with an approved cancer dx, so the system denies, stating no auth or not covered. I am trying to work with our coding department to get some documentation to show that we can move this dx to the 2nd, 3rd, or 4th placement. They insist that the "reason for visit" is to receive chemo, so this has to be primary. This is causing a TON of needless appeals. Any suggestions? Any documentation? HELP!
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki V58.11 primary or secondary or tertiary. Does order matter?
- Thread starter mmajor
- Start date
mitchellde
True Blue
V58.11 is a first-listed only dx code. This is stated in the coding guidelines. If you are being denied because your drug and the cancer dx do not match then it is a medical necessity issue and place the V58.11 secondary will not fix it. However if you drug is not chemo then do not use V58.11. Not all antineoplastic drugs are chemo.
MnTwins29
True Blue
Check the payers
While Deborah is correct about the coding guidelines and V58.11 should always be listed first, payers sometimes DO make thier own rules that go against the guidelines - even government payers.
For example, we all know to code for diabtes first then the manifestation. However, in the NGS LCD for HBO, if it is used to treat a diabetic ulcer, they deny claims that list the 250 code first - they are looking for the 707 code first, then the diabetes.
So for the question, be sure to check these payers for any rules they have that may go against coding guidelines.
While Deborah is correct about the coding guidelines and V58.11 should always be listed first, payers sometimes DO make thier own rules that go against the guidelines - even government payers.
For example, we all know to code for diabtes first then the manifestation. However, in the NGS LCD for HBO, if it is used to treat a diabetic ulcer, they deny claims that list the 250 code first - they are looking for the 707 code first, then the diabetes.
So for the question, be sure to check these payers for any rules they have that may go against coding guidelines.
mitchellde
True Blue
The coding guidelines for ICD-9 and 10 are mandated by HIPAA for adherence. Therefore payers cannot have their own rules regarding diagnosis code assignment unless they are a non HIPAA such as work comp. look on page one of the guidelines
RachRuef91
New
Payer Difference
We code different for commercial payers vs. Medicare. Medicare we code the cancer code first, commercial we code the V-code first. Payers are not supposed to have their own rules, but it seems they find ways to "sneak" around the guidelines sometimes!
We code different for commercial payers vs. Medicare. Medicare we code the cancer code first, commercial we code the V-code first. Payers are not supposed to have their own rules, but it seems they find ways to "sneak" around the guidelines sometimes!
mitchellde
True Blue
The diagnosis coding guidelines are not Medicare guidelines, they were created by the CDC for compliance when applying the code set and they mandated to be adhered to under HIPAA, the only payers they do not apply to are non HIPAA like work comp. if you use the V58.11 as a secondary code it is non compliant, if you code the diabetes code secondary for diabetic complications then it is non compliant. These rules were put into place for consistency. A payer cannot dictate which dx codes you can use or what order they can be in. They can make directives regarding medical necessity and coverage. If you "adjust" your dx code assignment to meet a payer "rule" you may be assigning a code that is incorrect for the patient.