Wiki DIAGNOSIS CODE INAPPROPRIATELY CODED

[caringpeds]

Hello Everyone,
I need your Help!!!
I work for a pediatric office. We have been seeing a lot of kids with the same or similar symptom's, nausea with vomiting, diarrhea, abdominal pain and gastroenteritis. The most confusing part is that the the same insurance either paid the claim or denied it. It's like they pick and choose which claim will get paid. We are billing it with the primary code as nausea and vomiting (R11.2), (2) Diarrhea (R19.7) and (3) gastroenteritis (A09) or/and Abdominal pain (R10.0). We have tried using diarrhea as a primary code and denied as well. Thank you so much for taking the time to read this!

 

[lgardner]

Hello Everyone,
I need your Help!!!
I work for a pediatric office. We have been seeing a lot of kids with the same or similar symptom's, nausea with vomiting, diarrhea, abdominal pain and gastroenteritis. The most confusing part is that the the same insurance either paid the claim or denied it. It's like they pick and choose which claim will get paid. We are billing it with the primary code as nausea and vomiting (R11.2), (2) Diarrhea (R19.7) and (3) gastroenteritis (A09) or/and Abdominal pain (R10.0). We have tried using diarrhea as a primary code and denied as well. Thank you so much for taking the time to read this!

I don't see an issue with these diagnosis, except perhaps if the provider is stating that the patient has confirmed 'infectious gastroenteritis' (A09), you wouldn't need to code the symptoms, too.

What reason is the payer giving for the denials?
What are you billing for? E/M? testing?

 

[TThivierge]

Hi Caringpeds,
I believe I know the reason you had insurance denial . It could be ...the Excludes 1 Rules which states cannot bill same time dx A09 and R19.7. Or it could be denied cause Dx R19.7 is a unspecified dx too which maybe the reason if have as first dx on claim. Sometimes certain unspecified dx code are denied when first dx listed on claim. Also dx A09 is considered SIBO (Small Intestine Bowel Overgrowth) of bacteria. To prove this did provider order a lab test to confirm it? If not maybe another denial reason by the payer.
Well I hope I helped you somewhat
Lady T

 

[caringpeds]

I don't see an issue with these diagnosis, except perhaps if the provider is stating that the patient has confirmed 'infectious gastroenteritis' (A09), you wouldn't need to code the symptoms, too.

What reason is the payer giving for the denials?
What are you billing for? E/M? testing?

Thank you for answering my question. The denial reason as stated on the EOB: "DIAGNOSIS CODE INAPPROPRIATELY CODED" But it makes sense the dx code for A09 was without any test or lab findings. Will fix and correct the claim. Have a great day!

 

[caringpeds]

Hi Caringpeds,
I believe I know the reason you had insurance denial . It could be ...the Excludes 1 Rules which states cannot bill same time dx A09 and R19.7. Or it could be denied cause Dx R19.7 is a unspecified dx too which maybe the reason if have as first dx on claim. Sometimes certain unspecified dx code are denied when first dx listed on claim. Also dx A09 is considered SIBO (Small Intestine Bowel Overgrowth) of bacteria. To prove this did provider order a lab test to confirm it? If not maybe another denial reason by the payer.
Well I hope I helped you somewhat
Lady T

Thank you for answering my question. Yes, It makes sense the dx code for A09 was without any test or lab findings. Will fix the claim and resubmit. Have a great day!