Wiki 27786 with S89.311A

[dmakepeace]

We billed 27786 with DX S89.311A and insurance denied for procedure/DX not compatible.
Xrays revealed Salter Harris I distal fibula fracture and closed treatment of right Salter Harris I distal fibula fracture was done. Does anyone know what we coded incorrectly? Thanks

 

[MI_CODER]

I don't understand why the insurance is saying the procedure and diagnosis codes are incompatible. I would definitely fight this as I believe what was coded is correct (based on the info you provided). Was the correct laterality modifier used on 27786? I'm not sure if this would throw an "incompatible" denial but it's definitely worth double checking.

 

[dmakepeace]

Hi, thanks for your reply. Yes, we billed the correct laterality/RT. We also sent in the medical records and they still upheld the denial. I did find some info online about studies that challenge that SH type I distal fibula injuries are in fact epiphyseal fractures and therefore not necessary to cast for 3-6 weeks. The denial said the determination based on industry standards and guidelines established by AMA and/or World Health Organization. I am still digging to see what I can find to support that decision.