Wiki Denial

[Gemini18]

We are working in a denial from Medicaid due to a diagnosis. The diagnosis is "suspected domestic abuse" (995.80).

How do we correct this claim?

I think it should have been an E967.3 (Alleged, suspected) to begin with, the other diagnoses are Carotid dissection, Headache and Vision Loss.

 

[mitchellde]

First E codes cannot be first listed. Second the code 995.80 is not for suspected domestic abuse, it is a code for specified adverse effects not classified eleswhere and it requires an addition code for any associated injury and an E code for the nature of the abuse and the perpetrator. The E code you have selected is not for alleged or suspected it is to Identify the perpetrator of child and adult abuse. Be careful when using these codes that you do not read into the descriptor words that are not there. If the physician documents that there is a suspician of abuse then you do not have enough to code this. You must then code the symptoms.

 

[Gemini18]

First E codes cannot be first listed. Second the code 995.80 is not for suspected domestic abuse, it is a code for specified adverse effects not classified eleswhere and it requires an addition code for any associated injury and an E code for the nature of the abuse and the perpetrator. The E code you have selected is not for alleged or suspected it is to Identify the perpetrator of child and adult abuse. Be careful when using these codes that you do not read into the descriptor words that are not there. If the physician documents that there is a suspician of abuse then you do not have enough to code this. You must then code the symptoms.

Thanks Debra -

I am auditing the denied claim. I know the Ecode does not go first. I believe the 995.80 was being used as "abused person, NOS", the document does state she was abused by her spouse. I asked all the questions you are asking me. The records does state mulitple admissions for different reasons: ex: broken nose, multiple marks on body, etc. The physician states "suspected/alledge" in his documentation. I just don't see where it should have been coded as a definite sign of "domestic abuse", I was thinking the E code would have worked better.

 

[mitchellde]

If he says suspected or alleged then you cannot use the E code either, remember we cannot code suspected dx only known. So code the injuries and use an E code for unspecifed as to accident.

 

[JMeggett]

Karen, I agree with Debra on all accounts...but another aspect to think about is Medicaid MAY not want to cover claims related to abuse. I have found that if they suspect abuse they think a claim should be opened with Crime Victims through the state. Just a heads-up if you flat can't get them to pay with all the dx's correct.

Jenna

 

[Gemini18]

Karen, I agree with Debra on all accounts...but another aspect to think about is Medicaid MAY not want to cover claims related to abuse. I have found that if they suspect abuse they think a claim should be opened with Crime Victims through the state. Just a heads-up if you flat can't get them to pay with all the dx's correct.

Jenna

Thanks Guys