Wiki 22612 Dx help

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Billing@heyclinic.com

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I have a claim that keep getting rejected in the clearinghouse by the payor for "Procedure Code 22612 has not met the associated Dx code relationship criteria for CMS ID L37848". I have checked the coding book and the dx code M48.062 is a correct code for this procedure. What am I doing wrong?
 
Billing@heyclinic.com said:
I have a claim that keep getting rejected in the clearinghouse by the payor for "Procedure Code 22612 has not met the associated Dx code relationship criteria for CMS ID L37848". I have checked the coding book and the dx code M48.062 is a correct code for this procedure. What am I doing wrong?
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In addition to what Amy is stating, if you do not have a diagnosis that meets LCD, you will need to append a modifier such as GY or GZ, depending on if an ABN was signed. The modifier is required by the clearinghouse because it will determine whether it will deny as patient responsibility or provider responsibility.
 
Also, what is usually wrong is that the primary diagnosis is just the incorrect one. Most times these patients requiring lumbar fusion have multiple diagnoses/problems. If you are the coder you would want to double check everything against the operative report. If you're the billed/edit cleaner you would want to send it back to coding for review. In my experience it would be rare that a fusion would be done and would not meet the LCD. It "could happen" but that would become a conversation with my provider if they are performing cases that don't meet it. Further, the ABN scenario would be a whole separate discussion! :) Especially if this was a multi-level fusion with other things going on that may or may not have required an IP admission. <side thoughts>
 
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