Billing D63.1 as prime for Hematology office visit

kathleeng

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I know coding guidelines state that the CKD stage should be primary then D63.1, but I am wondering if that is different when seeing a patient at a hematology/oncology office. Currently billing 99215 with D63.1, N18.5- is this correct since we are treating the hematology based code or do we stick to the coding guidelines? There seems to be mixed opinions on this. Anyone familiar with this specific instance?
 

mitchellde

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The code conventions in the code book take priority so the D63.1 States to code first the underlying CKD which makes D63.1 a secondary only allowed code. There are no exceptions for this rule.
 
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so if I understand you correctly the N18.9(or whatever stage) should be documented before D63.1 not matter what? Co worker stated insurance won't pay if the D63.1is not first since it is the blood disorder. Please clarify.
 

thomas7331

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so if I understand you correctly the N18.9(or whatever stage) should be documented before D63.1 not matter what? Co worker stated insurance won't pay if the D63.1is not first since it is the blood disorder. Please clarify.
The guidelines for this code haven't changed since the posts above were written - D63.1 is a manifestation code that requires the underlying condition be coded first. If an insurance won't pay this, that's a different matter entirely and you'd have to take that up with them. Payers don't always understand coding guidelines and it's not uncommon that they may program their systems or deny claim incorrectly as a result.
 

kathleeng

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The guidelines for this code haven't changed since the posts above were written - D63.1 is a manifestation code that requires the underlying condition be coded first. If an insurance won't pay this, that's a different matter entirely and you'd have to take that up with them. Payers don't always understand coding guidelines and it's not uncommon that they may program their systems or deny claim incorrectly as a result.
Yes, I agree. Since my original post, we bill with the order per the CPT book guidelines of N18.- primary, with D63.1 secondary. There are a couple payers that still want D63.1 primary, however most don't or they now deny for invalid primary diagnosis code.
 
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