Our practice has experienced a new trend recently with BCBS, Humana and Wellcare mostly, where 99214 office visit is denied for the diagnosis codes submitted. An example is a patient with 99214 and dx codes of M25.511 Bilateral shoulder pain, M25.569 Pain in joint of lower leg, M25.561 Arthralgia of right knee, M51.36 Degenerative disc disease, W19.XXXXA Fall. Those are all the dxs the provider addressed during the visit, so we're not sure where we're going wrong with the dx codes submitted on the claim. Any help is much appreciated!
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Wiki Claims rejected for 99214 with dx codes
- Thread starter melodi.kaelin@comcast.net
- Start date
Orthocoderpgu
True Blue
The first thing I would do is focus on your coding.
M25.511 is right shoulder pain, not bilateral
M25.569 is pain in unspecified lower leg joint. Why can't a more specific code be used?
The W19 code shows that the patient fell. Are there any injuries from this fall? According to your diagnosis codes submitted, no.
If I am at the insurance company, I would want better information.
M25.511 is right shoulder pain, not bilateral
M25.569 is pain in unspecified lower leg joint. Why can't a more specific code be used?
The W19 code shows that the patient fell. Are there any injuries from this fall? According to your diagnosis codes submitted, no.
If I am at the insurance company, I would want better information.
I'd also wonder why M25.569 and M25.561 were coded on the same claim.
Is the pain in the right knee? If so, you'd only keep the M25.561 pain in right knee. It makes no sense to code pain in unspecified knee (M25.569) and pain in right knee (M25.561) on the same claim.
The knee is either unspecified or right knee. It can't be both simultaneously.
And if the documentation says pain actually bilateral, in both the right knee and another knee, well...by default that means the "other knee" would be the left. So in that case you'd use M25.562 for left knee and M25.561 for right knee.
The unspecified knee M25.569 needs dropped either way, because your laterality IS specified.
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Payers are getting savvier about diagnosis coding. Sometimes this means that they'll use ambiguous or contradictory diagnosis coding as a reason to kick claims back to you.
Your best defense against this is to be as accurate and specific as possible in your diagnosis coding.
Your best defense against this is to be as accurate and specific as possible in your diagnosis coding.
Thank you everyone! this is very helpful and please keep posting any other insight you have. I think our issue may be the way the codes are worded in the software our provider is using does not always match ICD-10 so we are going to tackle that problem on our end. All of the above advice helps a lot in knowing what to avoid/change for what the doctor is selecting.
Orthocoderpgu
True Blue
Let's hope that this starts the "change" that needs to happen where this is happening. Doctors and coders need to work together. Had an experienced coder reviewed this with the provider before billing, it's very possible that with coding changes it would have supported a 99214. It seems that this organization is allowing the doctors to code. As you can see, doctors are not coders. If the doctor is choosing the diagnosis codes, are they allowed to choose the E/M code too? Equally bad idea if that is the case. This makes it hard on you if you're just working the billing side and or denials. As you can see improper coding slows the process down. Your Revenue Cycle Manager probably wants to get the payment. That will happen faster with a good certified coder involved before it gets sent to insurance. Good luck and keep posting!