Question Billing Guidelines for Secondary Payors Regarding Dx Coding Changes

Best answers

I'm looking for some solid documentation on what sort of federal guidance there is on billing a claim to a secondary insurance with dx coding changes.

Obviously, CPTs/HCPCS must be the same between both payors. It makes sense to me that dx codes should also be the same; thus, if the primary payor is billed, pays, and then a dx change occurs, no matter how small, the primary must be corrected; you cannot simply bill the secondary with the new codes. Another example: If the secondary ins does not allow a dx that the primary has already paid on, coding reviews and determines that a dx change is appropriate, the claim with the primary ins should be corrected rather than just correcting the claim to the secondary.

However, I'd like to find documented guidelines on this.

Any help would be appreciated!


True Blue
Best answers
I believe the False Claims Act would apply here just as it would in any other case. If you've identified through a coding review that a claim was submitted with incorrect information, then at that point in time, you essentially have a false claim on your hands and failure to correct it by submitting a new claim could be considered an intentional violation since you are at that point knowingly acting on the information you have. In practice, the corrected diagnosis may or may not have any effect on payment and may not be a serious issue for reporting purposes. But rather than trying to guess, the safer and better practice is to submit all corrections to all payers whenever any error is found.