Wiki Will insurance pay for tx of dry skin not assoc with other dx?

[sblacke68]

Hi,

Dry skin has a dx code, L85.3, but is that dx enough to support the medical necessity of a dermatologist office visit, established pt?

Would insurance pay for such a visit, if not symptomatic of another problem (psoriasis, eczema)?

Wouldn't this be a visit for a PCP to handle, if anything, and not a specialized practice (dermatology)?

Thanks!!

 

[thomas7331]

I don't think you can judge medical necessity just based on a diagnosis code alone - you'd need to look at the entire note for context. Certainly if a patient has a complaint or symptoms, that is sufficient to support necessity for a visit to a provider, though it may only warrant a low level code if the provider's assessment is that it is a minor or self-limited problem. As for whether or not an insurance would pay for this, that is a benefit question that would be specific to the patient's plan. Some plans allow patients to self-refer to specialists which would suggest the insurance company would not have a requirement that this be handled by the PCP first.

 

[sblacke68]

Thanks, I agree on your points.