Help with appealing this denial to get payment, if possible.

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Las Vegas, Nevada
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Scenario: Patient came into urgent care to establish primary care. Chief complaint is Establishing pcp. (I work at a facility that offers pain management, physical therapy, urgent care and primary care).
Primary code is Z00.00 followed by an F- code, Z-code and J-Code.
Insurance denied claim as being a routine visit. (INS: Healthscope).
Doctor orders bloodwork, discusses weight management, and report to ER for any signs of chest pain, shortness of breath, sign of distress and stroke.

I feel this is getting denied because the Z-code is listed first. If I was to rearrange the order, would it be paid?
And I remember I got told this but I can't remember the finer details it's been too long, but is there a specific order to put dx codes so they will get paid? If I remember from what I was told, Z-codes generally go last as most insurance companies will not pay if the primary is a Z-code.

Can someone please help me understand this? (Also, I don't code the bills out, the doctor/physician does).
 
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I'd like to try I processed provider appeals for UHC. Right the Z code should not be listed first. The F code is mental health and the J-code is respiratory. Why couldn't have any of those codes been listed first. Why are you using dx code Z00.00. That code is used when there is no suspected dx or dx. But your listing to additional diagnosis it does not correlate. There is a code or PX exam with normal and abnormal findings. I'd probably deny the appeal if the submitted diagnosis does not match the documentation.
 

Orthocoderpgu

True Blue
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Payment from insurance is based on "Medical Necessity". That's the very foundation of reimbursement. If the purpose of the visit was to "establish care" there is no medical necessity. If the physician did not treat a medical condition, there is no medical necessity.
 

thomas7331

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I agree, 'establishing PCP' does not support medical necessity and actually does not really tell you anything about why this patient was seen or examined. Per ICD-10 guidelines, the first-listed code should be the code for "the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided." But there is no code for an encounter to 'establish care' so no way to tell you which code should be listed first - you don't know if the patient was there because they needed a provider to take over ongoing care of their chronic conditions or if the just hadn't had a routine physical in a while.

I've always advised providers not to use 'establish care' as a chief complaint because it doesn't give adequate information for coding. Rather, the provider should document either that they are performing a routine physical or else describe the particular conditions that are requiring ongoing care.
 

Jlyak@live.com

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Local Chapter Officer
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Z00.00 cannot be billed unless its the patients wellness/preventative visit. One of my doctors loves to use it as his last diagnosis due to speaking with the patient about regular stuff and its constantly denied as needing to be listed as the primary diagnosis. I've notified the office manager to let him know he cannot use that code in our allergy clinic, but he still uses it so now I just remove it from his charges.
 
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