Wiki Diagnosis code denied T161XXA

[kguzikowski]

Physician ENT billed 99204 with T161XXA -99204 denied by Commercial Payer as DX Inconsistent with Place of Service. Only an E/M was performed. Surgery is to happen at a later date. T161XXA is a billable and the foreign body was not removed at the time of the E/M at the office. Surgery was not scheduled for that day or the next day. Why would it be denied based on diagnosis code at the office with an E/M ?
T16.1XXA is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes
Foreign body in right ear, initial encounter (Primary Dx)

 

[thomas7331]

There is no such thing as a diagnosis being inconsistent with a place of service, and there is no reason that this diagnosis would not be valid for an office E&M service. I have no idea why a payer would say such a thing and it sounds like a mistake to me. I would call the payer and insist that they either a) fix their mistake, or b) direct you to their policy or other resource which would explain in writing why they would not allow this diagnosis for the services you've billed.

Commercial payers are notorious for having a poor understanding of coding, and I've known many of them that do not even employ certified coders. So they often make errors, and due to their ignorance will often try to make you think that the error is yours instead of theirs. If you've coded your claim correctly and in accordance with their reimbursement policies, then you should not have to search for another diagnosis in order to get a correct payment determination. Stand your ground with them.

 

[thescientist8]

Did the patient feel any pain, and was it noted? If yes, I would use that as primary DX and T16.1XXA as secondary DX.

 

[kguzikowski]

Pain noted as-
The patient does not have any pain unless there is attempts to remove the foreign body. 　

 

[kguzikowski]

Thanks for your input appreciate it.

 

[mitchellde]

perhaps you need a 57 modifier on the E&M to show that surgery is planned and this is the preoperative work up?

 

[asowder]

perhaps you need a 57 modifier on the E&M to show that surgery is planned and this is the preoperative work up?

57 can only be used if a surgery was performed on the same day as the office visit or the day after. She stated in her opening question that this was not the case. Unfortunately it won't work for this. It was a great thought though!