Wiki ZELIS HELP!

[jessieraewinn@yahoo.com]

Hi, so I am getting increasingly frustrated with Zelis coding denials. I keep getting "Procedure not compatible with diagnosis" denials. For example with closure gastrostomy surgery 43870, we are getting a denial for dx code K31.6 (fistula of stomach & duodenum). I have been using these codes together for years. I checked the coding software I use & K31.6 is the number 1 code listed under 43870. Whenever I call Zelis they provide zero help. Does anyone have a document that shows the dx codes that they don't like in relation to specific CPT codes? Or does anyone know how I can get these denials paid and have had luck?

Thank you in advance- rant ended haha

Jessie W, CPC

 

[iowagirl77]

They might be considering that K31.6 would be more appropriate with 43880 than 43870. I assume you have already confirmed that the procedure and diagnosis are both correct? If 43870 is the correct procedure and there is not a more appropriate dx, I would appeal with records. It is hard to say what all they have put in for their edits, but if you have coded properly I would appeal it.