Cindy01
Contributor
Is it true that you can not use Fatigue as a primary diagnosis on out patient labs?
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Wiki Fatigue as primary diagnois
- Thread starter Cindy01
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Pam Warren
True Blue
There's a difference between "can you use" and "will you get paid". Fatigue is a perfectly good reason for a provider wanting to get some diagnostic lab work, but it's not generally a covered diagnosis for a number of lab tests. However, correct coding indicates that you code what the provider indicates on the order.
becca051
New
We started getting denials for it being the primary dx on April 1 this year.
Captain74
Guru
R53.81, R53.82, and R53.83 were added to the outpatient code editor as unacceptable diagnosis codes and we are getting a lot of rejections as well and have not been able to come up with a solution. Posting here in case anyone comes up with an idea. https://www.cms.gov/medicare/coding-billing/outpatient-code-editor-oce/quarterly-release-files
I emailed the CMS OCE Integration team and they replied that edit 113 is being updated in the October 2025 release to bypass outpatient claims as it was missed in the April release. If we don't have issues with timely filing we are going to file the claims after 10/1/2025. That's the only suggestion I can come up with.
Cynthia Hughes
Expert
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Not sure of the amount of money involved but that sounds like a totally unacceptable response with denials dating back to April. If your practice is connected with a clinical laboratory professional organization, it might be helpful to make them aware of this issue and request advocacy assistance. Cindy
jrollo1270
New
Would you be willing to share their response with us?
For claims that have already gone out and are now denying stating that it is an inappropriate primary/sole diagnosis code, are you all requesting additional diagnosis codes from the physician, or are you waiting to see if it is corrected Oct 1, 2025 and just requesting the claim be re-reviewed by the payer?
This was their response, "Edit 113 is being updated in the October 2025 release to bypass outpatient claims. The bypass was missed in the April release."
Prior to filing we have queried to see if there are additional diagnosis that should be added they may have left out. We can't ask that they specifically add additional dxs. If there are no additional dxs to add then we will wait to refile after 10/1/2025
jrollo1270
New
Thanks, I emailed CMS today and received the following response:
The Medicare MACs have been given instructions on how to handle these claims. A permanent correction will be installed for October 1, 2025. Please contact your MAC for questions/concerns.
Thank you!
We are pursuing this with our MAC (NGS) to see if we need to wait until the Oct update.
Thanks for sharing!!
The Medicare MACs have been given instructions on how to handle these claims. A permanent correction will be installed for October 1, 2025. Please contact your MAC for questions/concerns.
Thank you!
We are pursuing this with our MAC (NGS) to see if we need to wait until the Oct update.
Thanks for sharing!!