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heart123

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I have a claim that was paid and it was not the dx code that we got the auth for (i know they can recoup )but would yall send in a corrected claim before they even ask for it back??
It was a dx that the pt had just not what they got the auth for
I appreciate any thoughts
I was thinking to wait til they ask for it back (if they ever do)
 
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The diagnosis code on your claim needs to reflect what is documented in the medical record for that encounter. You can't submit a diagnosis code that was used to get an authorization if that code is not supported by the record itself.

If your code on the claim was wrong, based on the record, then I would submit a corrected claim, but otherwise I wouldn't pay any attention what was used for the authorization.
 
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Hi Thomas the dx i used was in the medical record But i am being told we need to send a corrected claim because the dx used was not the dx code when the girls got the auth (hope i said that right)
i can still use the code that is in the record is that right? The are afraid it will get recouped??
 
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heart123 said:
Hi Thomas the dx i used was in the medical record But i am being told we need to send a corrected claim because the dx used was not the dx code when the girls got the auth (hope i said that right)
i can still use the code that is in the record is that right? The are afraid it will get recouped??
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You can only use the diagnosis on the medical record - if you use a different diagnosis than what's in the record, then you're submitting a false claim. If they used a different diagnosis to get the auth, then that was their mistake - you don't make it right by compounding the mistake.

If the claim got paid, why are they worried? You gave the payer an accurate claim and they made the decision to pay it. If the claim gets recouped because of this at some point in the future, then you will need to deal with the problem at that time, either by getting the payer to revise the auth, or by having the provider do an addendum to the record if needed. For now, you did the right thing and your provider was paid correctly for it, so just leave well enough alone.
 
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thomas7331 said:
You can only use the diagnosis on the medical record - if you use a different diagnosis than what's in the record, then you're submitting a false claim. If they used a different diagnosis to get the auth, then that was their mistake - you don't make it right by compounding the mistake.

If the claim got paid, why are they worried? You gave the payer an accurate claim and they made the decision to pay it. If the claim gets recouped because of this at some point in the future, then you will need to deal with the problem at that time, either by getting the payer to revise the auth, or by having the provider do an addendum to the record if needed. For now, you did the right thing and your provider was paid correctly for it, so just leave well enough alone.
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Thank you
 
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ddcool said:
I would send in the correction.
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Based on what was described here, the claim submitted is correct. It was that the auth was obtained with an incorrect dx. It states it was for chemo. So let's say the auth was obtained as colon cancer C18.9. But the patient actually has bladder cancer C67.9.
I'm understanding the claim was submitted as correct dx bladder cancer C67.9. Since the auth was authorized as C18.9, the original poster is asking if a claim with C18.9 should be submitted.
The answer to that would be no. C18.9 would not correct the claim, in fact it would do the opposite.
If the patient is returning for multiple chemo treatments, I would advise to correct any future auths. If you want to be super cautious, contact the insurance about the already authorized and paid claim to see how to correct the auth.
The claim was never incorrect in the first place. The AUTH was incorrect. Unless I'm misunderstanding the situation.
 
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