izsaba16
Guest
I handle billing for a small Physical Therapy office. We've been seeing a patient since January of this year, and all their visits have been paid without any issues. However, on April 12th, we received a denial for their visit in late March, citing the reason code "The diagnosis is not consistent with the procedure." Surprisingly, the diagnosis codes and procedure codes remained unchanged. Upon reviewing the specific Explanation of Benefits (EOB), I noticed duplicate claims for that Date of Service (DOS). I suspected that might be the issue, and the error message was incorrect. I contacted a representative at the insurance company, and she agreed that it seemed like a mistake, as she could see all previous claims with identical codes were paid. She submitted it for review and mentioned I should hear back in about 15 days. However, it's been over a month, and I haven't received any updates.
Regrettably, I inadvertently submitted the patient's next visit without resolving the previous issue and received a denial for that visit today. (Yes, I acknowledge it's my fault, but I'm the sole person handling billing, denials, and processing and applying payments here, so I have a lot on my plate.)
I reached out to another representative at the insurance company for clarification on the issue. This time, I received more detailed information on the denial reason. It's based on the ICD-10-CM Excludes1 note guideline. Diagnosis codes H81.10 with R42 and R42 with H81.10 signify two conditions that shouldn't be reported together unless they're unrelated.
My question is, is the provider allowed to remove a diagnosis so we can receive payment for this? He won't be adding anything extra, and it won't change our reimbursement, so I don't believe this would be fraud. However, I'm unsure if it's allowed after it's already been submitted.
Regrettably, I inadvertently submitted the patient's next visit without resolving the previous issue and received a denial for that visit today. (Yes, I acknowledge it's my fault, but I'm the sole person handling billing, denials, and processing and applying payments here, so I have a lot on my plate.)
I reached out to another representative at the insurance company for clarification on the issue. This time, I received more detailed information on the denial reason. It's based on the ICD-10-CM Excludes1 note guideline. Diagnosis codes H81.10 with R42 and R42 with H81.10 signify two conditions that shouldn't be reported together unless they're unrelated.
My question is, is the provider allowed to remove a diagnosis so we can receive payment for this? He won't be adding anything extra, and it won't change our reimbursement, so I don't believe this would be fraud. However, I'm unsure if it's allowed after it's already been submitted.
diagnosis codes, diagnosis coding