Wiki BCBS -diagnosis issue

[swilliams2]

Just wondering if anyone else is having this issue and if so how your office is handling it.

We are in Florida and bill all out of state BCBS plans to our local carrier. What we are finding is that out of state plans are rejecting a lot of our claims due to diagnosis. Specifically, when there are multiple diagnosis on a claim BCBS is only looking at the first diagnosis and not how we have them linked. For example:

99396 linked to V70.0
84443 linked to 244.9

They will pay the first line and reject the second stating the patients policy does not cover the 84443 with a routine dx. Clearly it is linked to 244.9 but they are only looking at V70.0.

We have to call and have the claim reopened and processed correctly but the problem seems to be getting bigger everyday!

Anyone else going through this?

 

[wannabecoder]

It could be a system issue with the carrier. I suggest following up with your BCBS contract/PR rep on this to see if this is something related to processing errors or a true billing issue related to a pmt policy.

 

[EricaR]

We did have a similar issue with our colonoscopies, these were the only claims we specifially put a dx pointer on, for instance we would bill 45385 v76.51 211.3 with a pointer to dx 2. however, they would only process as if the 211.3 were the only dx on the claim. Kind of sounds like the exact opposite of whats happening to you but we eventually were told not to add a specific pointer and just allow pointers to be 1,2,3,4 etc. Sorry probably not super helpful. We did get that information in writing from our rep. as BCBS policy specifically told us to apply the dx 2 pointer and all CSR would give us confliciting info when we called. Hope that helps somewhat...

 

[xlbctso]

I would challenge this. Do you know for a fact that the member's benefit prevent this HSC from paying with this routine diagnosis code (even though you didn't file it this way)? The reason I say this, is that the Home Plan for the member cannot apply provider sanctions to another Blues Plans' providers. Denials based on diagnosis codes are typically medical policies, not member benefits - that would have to be in the member's actual subscriber agreement. Contest it - and find out whether there is an issue passing the diagnosis code on the second service in the Blues Plans ITS software in Florida. Don't take no for an answer when you are filing appropriately.

Louise

 

[mitchellde]

what was the test being peformed, if it was as a screeniong then use the screening V code, if it was because the patient is on medication for this condition then use the V58.83 witrh the V58.61,
If the patient was symptomatic and the provider is looking for a dx then use the symptoms, rarely would the code for the condition be used for a lab test for the condition. Also you have chosen an unspecified code, many payers have decided top put edits in for these codes specifically as unspecified is often translated as not documented.