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BCBS rejecting all claims w/ unspecified dx codes

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shanamarie

Guru
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180
Location
Eagan
Hello, Is anyone else having issue w/ BCBS rejecting all claims w/ an unspecified dx code? Trying to figure out if we have a clearing house issue, or if they have some kind of new policy that we aren't aware of. Seems like this just started last week.
 
shanamarie said:
Hello, Is anyone else having issue w/ BCBS rejecting all claims w/ an unspecified dx code? Trying to figure out if we have a clearing house issue, or if they have some kind of new policy that we aren't aware of. Seems like this just started last week.
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This is something you'll likely start to see more frequently with many payors. Payers are getting more savvy with codes & guidelines and pushing back on unspecified diagnosis codes.

Of course, as coders, we should be coding to the highest specificity anyhow.

If a provider's documentation is lacking and keeping the coder from assigning a more specific diagnosis code, this is a great opportunity to educate them. The documentation should already be specific for the integrity of the medical record, of course, but sometimes a provider is resistant to change until it impacts the bottom line.
 
Anecdotally, I'm not seeing this on diagnosis codes where the best option truly is the unspecified code. (Ex - J44.9 COPD)

However, I have started to see pushback on codes where typically there should be a more specific code available. (Ex - C34.91 malignant neoplasm of right lung, unspecified could get pushed back. The payer may want the code that specifies the specific location in the right lung: C34.11 right lung upper lobe or C34.31 right lung lower lobe)
 
Teetertotters said:
We are seeing this issue suddenly as well, specifically for BCBS as you mentioned.
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I have been told that BCBS inadvertently turned on some kind of edit that was rejecting most of our claims even though there wasn’t a dx issue. 200+ claims were affected for our clinic. They have since turned this off, so hopefully this shouldn’t be happening anymore. Approximate date range for the issue was claims that were submitted between 5/23-6/1.
 
shanamarie said:
I have been told that BCBS inadvertently turned on some kind of edit that was rejecting most of our claims even though there wasn’t a dx issue. 200+ claims were affected for our clinic. They have since turned this off, so hopefully this shouldn’t be happening anymore. Approximate date range for the issue was claims that were submitted between 5/23-6/1.
Click to expand...
Thank you so much for that information! That is very helpful.
 
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