Wiki Denial for inappropriately coded

[patdow]

We have an invoice for community health choice that was denied for inappropriately coded. The ICD 10 codes are R11.2, N18.6, D89.9, and Z94.4. The CPT code is 99223.

This patient has a few other invoices with the exact same ICD 10 codes but the CPT code was 99233. They were paid.

Can someone please advise?

 

[Pam Warren]

Are they denying based on the CPT code or the diagnosis code? You have submitted an initial hospital visit. Was this the initial visit? Are you the attending? If so, did you add the AI modifier? Was this a visit for a hospital round? (then code from 9923x) series.

The diagnosis code D89.9 is very, very nonspecific. That could be the issue as well.

 

[patdow]

Are they denying based on the CPT code or the diagnosis code? You have submitted an initial hospital visit. Was this the initial visit? Are you the attending? If so, did you add the AI modifier? Was this a visit for a hospital round? (then code from 9923x) series.

The diagnosis code D89.9 is very, very nonspecific. That could be the issue as well.

Thank you for your input. They did not specify which codes were being denied. I assume the ICD 10 codes. Yes, it was the initial visit. No, we were not the attending. CPT code is correct. We’ve used D89.9 many times with no issue.

 

[Dawkins1969]

Thank you for your input. They did not specify which codes were being denied. I assume the ICD 10 codes. Yes, it was the initial visit. No, we were not the attending. CPT code is correct. We’ve used D89.9 many times with no issue.

We have an invoice for community health choice that was denied for inappropriately coded. The ICD 10 codes are R11.2, N18.6, D89.9, and Z94.4. The CPT code is 99223.

This patient has a few other invoices with the exact same ICD 10 codes but the CPT code was 99233. They were paid.

Can someone please advise?

 

[Dawkins1969]

Have you found out any other information about this denial from CHC?

 

[sls314]

In reviewing the ICD-10 codes, I noticed that N18.6 is included, but the Z99.2 code for dialysis status is missing.

I also agree with Pam that D89.9 is very non-specific and may be contributing to the issue. Or, it may just be the Z18.6 without the corresponding Z99.2

Even if certain diagnosis combinations have been accepted in the past, many payers are increasingly enforcing ICD-10 guideline edits in claims processing. Just because a combination has slipped through previously doesn’t guarantee it will continue to be accepted in the future.