BCBS & ICD-10 Codes for PT

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Hello, we recently started getting random denials from BCBS stating "the diagnosis code(s) submitted is inconsistent with ICD-10 CM coding guidelines. From what we can find, we are not seeing anything wrong. It is all related to back-related ICD-10 codes (ie. M50.20, M54.2, M47.819, M54.9, M52.21, etc.) when billing out therapy CPT codes (97110, 97112, 97530, etc.). We are primarily seeing this with BCBS Fed and BCBS TX. Has any one recently had similar denials?
 
I will double check this for you tomorrow, but I believe I've seen edits that M54.2 can't be listed with M50.20. Again, I will check this for you tomorrow. I would look into that though. Try entering it into your encoder and see if there is an NCI edit or anything similar.
 
Hi HCiochetty,
Yes, I have clearly identified this issue working pathology denials this past Mid May while assisting my denial team with pathology denials. I actually posted some recent trends that I have discovered recently in the pathology forum that I wanted my pathology colleagues to be aware of when coding or working denials. The majority of the denials I have dealt with have been from BCBS, but I have CLEARLY seen this denial scenario reviewing denials from other payers too. The payers have become somewhat savvy and have set up all these "Excludes 1" edits to deny ~ (personally, I was afraid that it was going to be bigger than just the pathology department charges). Please feel free to take a peek at my post.
I jotted down all the diagnosis code(s) you provided and reviewing my ICD book - it clearly states diagnosis M54.2 has an "Excludes 1 edit" with diagnosis code (M50.-) therefore it would be inaccurate/incorrect/wrong to bill those two diagnosis codes together per our ICD guidelines. I wasn't sure what diagnosis M52.21 meant to offer any assistance (possibly a typographical error?).
The actual denial from BCBS actually stated something like "principal diagnosis is missing". As soon as I saw that code and reviewed the diagnosis codes, I already knew it was an "Excludes 1 edit" issue and referred to my book to make the necessary correction after reviewing the pathology report. It probably doesn't matter what specialty we are coding as long as we are all adhering to those "Excludes 1 edits" for proper diagnosis code or codes assignment.
Correct the invoice after reviewing the assigned diagnosis codes for "Excludes 1 edits" and you should probably be okay. I haven't had a long enough period of time to review if my corrections are perfect yet. I would probably need another 45 days for a payer to receive a corrected claim and respond. But I'll keep you posted as I receive those EOBs.
Thank you for listening and if you have any other issues, please reach out. Have a wonderful evening!
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
 
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