I could use some advice on a claim I have for a male patient. The insurance is BCBS. The billed code is 99213, and the dr coded the encounter with F07.81 and S06.0X9S. I have spoken to our coding department, and they are not giving me much help. The research I have done says that we need an external cause code. I am just looking for some guidance on what direction to take.
-
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 the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..
Question RHC claim denial
- Thread starter kellychamberlin520@yahoo.com
- Start date
-
- Tags
- diagnosis coding
What is the claim denial reason?
99213 WAS SUBMITTED WITH A SECONDARY DIAGNOSIS CODE AS THE ONLY, PRIMARY OR PRINCIPAL; THEREFORE 99213 IS NOT REIMBURSABLE.
I tried to put the S code first and the clearinghouse is throwing an edit because the code is a sequela, but when I put it in the BCBS code auditor in Availity, the response showed payable, but I know that tool isn't always accurate.
Okay, that makes sense. Your issue isn’t related to an external cause code. (It’s actually not common for an external cause code to cause a claim denial, which is why I asked for the specific denial reason.)
F07.81 has a “Code First” note instructing you to code the underlying physiological condition first.
The patient has post-concussion syndrome, but what specifically was the patient being seen for at that encounter? What was being evaluated or treated that day? That should generally be your primary diagnosis.
Your sequela code usage is fine. That falls under the “code also if applicable” note.
(One thing to note, though: S06.0X9S indicates that there was loss of consciousness of unspecified duration with the concussion. If the provider knows the duration of the loss of consciousness at the time of the concussion, then the more specific sequela code should be assigned instead. But aside from adding specificity if available, the use of the sequela code is appropriate.)
Okay, this makes a lot of sense! I was on the right track. Thank you so much for your help. I have an expired coding certificate due to the inability to afford CEUs and never being able to find a job after completion. I was blessed to land a job in the billing department of my local hospital and am currently enrolled in the CPB program through AAPC. This was such a helpful resource. I appreciate your time.