Abark77,
Are denials or down coding reimbursements due to Z dx codes as primary or unspecified dx codes used as primary dx on claim?
Lady T
Thank you. I have appealed each one. We are not in network with Humana and the majority of the claims are part of a passive network. The time spent with the patient is clearly documented in the notes. It is very time consuming but when I reach out to Humana, they are not helpful at all.Can you give some examples?
This should be appealed (as long as the original coding is appropriate), and improper denials referred to the state insurance board.
Depending on your institution's contract with humana, they may be able to get away with this. You'd have to look specifically at the contract language and perhaps renegotiate it.
We are having issues with Humana as well but they are denying r19.7, r19.5 all the things. I’m not sure how much more specific we can be in these situations.. any recommendations?Abark and Nrailman,
Unspecf Dx codes used instead of definitive dx which may create more denials. Get physician or provider to hopefully give clearer dx codes. Here are some examples ...
Unspecf. Dx Sometimes Used
N18.9 instead of N18.1 -better N18.6 show stages of CHKD
R19 Diarrhea instead of K59.1
R12 Heartburn vs K30
R19.5 blood in stool or fecal abnormal vs K92.1 Melena
M54.50 or M53.9 Back Pain but has more detailed dx such as M47, or M54.16
R51 Headache vs Migraines G43
Chronic Pain Syndrome G89 but no reason what causes it...back pain, emotional depression , Etc. other illness ???
Using Z dx codes some are primary (Z00, Z01, Z23) and some are secondary Z dx codes...the list is in ICD10 manual. I have seen DX Z09, Z85 & Z86 as first dx codes...need to add illness reasons.
I hope this data helps you somewhat
Lady T
What services are they denying, and on what basis?We are having issues with Humana as well but they are denying r19.7, r19.5 all the things. I’m not sure how much more specific we can be in these situations.. any recommendations?
A diagnostic colonoscopy when the symptom is diarrhea or positive cologard which is the r19.5- just say path report comes back clean no dx found.. we obviously leave symptom codes but they are paying the actual procedure but just will not pay on certain pathology code lines. We can bill 3 units of 88305, 1 unit 88312, and 1 88313 and they will not pay the 88305- but their reasoning is dx code issue. It’s super confusing because they will pay procedure itself and certain pathology code lines but not others.What services are they denying, and on what basis?
And same thing with our EGD’sWhat services are they denying, and on what basis?
As far as the egd if a patient has abdominal pain that wouldn’t qualify it as a egd screening correct? So therefore we couldn’t use the z code.. however when they have r10.9 and r19.7 and an EGD is performed but nothing found would we not leave the dx codes? When path reports come back we code straight from there and thats where we capture our k20-K29 codes. We have no other issues with any other payers as far as this and it’s just confusing as to why they will pay the procedure and certain pathology lines but not pay other path lines all in the same claim. I hope that makes sense! As far as colonoscopies the path reports are very detailed and always State whether polyp is k63.5 or a d code.. those are being paid fine its just when nothing is found so we leave symptom codes they kick back. We use r19.5 as positive cologard code because thats what it maps to but it still denies that code as well.Hi Macyoverstreet
Your providers need to give a definitive dx code not symptom code which is unspecified. Payers like details and lab results should support it . The dx code of R19.5 has many fecal abnormalities or unspecified. The dx R19.7 Diarrhea why not use K59 definitive dx? Use as last dx code related to colon dx Z12.11 or Z13.811 Also for EGD is related to esophagus stomach throat Etc see dx blocks of K20-K27 or R10.13 or R12. Alos follow it up with Z13.810 for encounter for digestive DO in upper gastro area or Z12 block look for cancer in this area per providers directions/documentation.
I hope you also look at lab results to code polyps D12 per colon area growth discovered or gastro ulcers or polyps in upper gastro system and add this as supported dx.
Lady T
Nope, they have a downcoding policy for level 4 and 5 based on claims information (so the diagnosis mostly). If they deem the diagnosis doesn't substantiate medical necessity for the level of service, they'll downcode and will require an appeal.We have seen Humana down coding our E&M visits without even requesting records. We have noticed its only 2 of our providers. The Humana rep only said to appeal but we want to report this to the insurance commissioner. Has anyone gotten any were with this type of issues with Humana?