Wiki How to know whether or not a specialized provider is able to address a diagnosis from a different specific category of codes?

[carlystur]

I have a Nurse Practitioner at our neuro-specialty practice who is and has been taking on patients that have headaches, migraines, etc. which is fine, but she also sees patients for anxiety and other mental health conditions with either ordering MRIs or labs or giving the patients prescription medication specifically for these mental health diagnoses. Does this depend on the patient's insurance company and our contract with that insurance for whether or not the NP can address them?

For some context, I have gotten denials regarding invalid diagnosis when the provider chooses mental health codes in addition to other head injury codes, like Concussion with (or without) loss of consciousness (injury) and Post Concussion Syndrome (mental health). My revenue cycle manager is requesting that I do not remove diagnoses from the Assessment section of the documentation (regardless of whether or not leaving them would be correct coding since we are currently using eClinicalWorks version e11). So, I've been having to either catch the claim and change that before it goes out to the insurance company the next day after the provider signs/locks the encounter. Or, I wait for the insurance company to deny the claim and change or remove the diagnoses with the codes that way. Mostly, I've been waiting for denials since I have a lot of work projects to work on in addition to my regular daily duties.

 

[thomas7331]

I don't think that any provider is limited to just a specific category or range of diagnoses. In any specialty, it's part of a provider's scope of work to understand not just the disease or problem that they are treating at a particular encounter, but also to take into account other conditions that the patient has or medications that the patient may be taking for unrelated conditions. These conditions may influence care and are appropriately reported by that provider. For example, a psychiatrist treating a patient for depression might note that a patient has CKD because this might influence what medications that the provider may or may not be able to prescribe to treat the depression. But it doesn't mean that because the psychiatrist isn't a nephrologist that they shouldn't be addressing the CKD or that the CKD should not be coded.

So I'm a little confused by your question and by why you'd need to be removing diagnoses from encounter notes or claims. Diagnoses should accurately reflect what's in the documentation, so if the provider in fact documented that they addressed that condition, then it shouldn't be removed. It sounds like maybe your claims are not denied for invalid diagnoses, but for diagnoses that are perhaps not covered or a covered by another payer, is that the case? That's a different issue entirely. Many payers carve out mental health claims to a separate contractor, so if the provider is treating a mental health issue, then those claims often need to be filed differently and are paid under a different benefit (or may not be covered if the patient doesn't have certain benefits or if your provider isn't in the patient mental health network.) You wouldn't remove the mental health diagnosis from the claim just to get it paid if in fact that's what's being treated. It sounds like perhaps someone needs to take a closer look at these denials and to try to understand exactly what is happening. Removing diagnosis codes for conditions that are accurately documented as relevant to the encounter isn't the correct way to resolve denials.

 

[csperoni]

Completely agree (as usual) with @thomas7331.
It is certainly not within the job description of a coder to question whether or not a clinician is qualified to address a particular condition. The diagnosis codes should be used for all problems that are documented as addressed.
I do have a sneaking suspicion that claims billed with a primary diagnosis of a mental health issue are being denied as covered under the behavioral health benefit instead of straight medical. Many plans carve out behavioral health to another company.
Depending on the particular situation, you may either need to:
1) correct the claim to reflect the correct primary diagnosis. And keep a lookout in the future to ensure the diagnoses are in the correct order.
2) bill the claim to the behavioral health provider. You may need to credential your provider with another network if they are in fact providing behavioral health services.
Here's an actual real life situation that I happened across recently. Patient saw cardiologist for testing. Patient is also transgendered. The cardiologist claim for echo was submitted F64.9 (gender disorder) primary and R55 (syncope) secondary. The medical insurance denied the claim due to primary diagnosis, and stated it falls under behavioral health. The biller working the denial then submitted the claim to the behavioral health provider. The behavioral health provider denied the claim because it's for an echo. The biller has been bouncing back and forth between the 2 companies, getting denial after denial. The coder needs to correct the order of the diagnoses on the claim. This is why it is helpful for billers to at least have a basic coding understanding.

 

[ckeeney]

I want to reiterate the code order. As a behavioral health coder, if the NP is seeing them for a head injury (your example) plus a mental health condition is the mental health condition due to the medical issue? Check for coding sequence and the use of the codes from the F0x.xxx series at the beginning of the mental health ICD chapter.

 

[carlystur]

Thank you all for your responses. I'm still a new coder here and learning the ropes of real-world coding and billing. I get sent denials from one of our billers to handle if they are a coding issue rather than a billing issue and I'm not sure if it's the biller's wording that is confusing me or the denial's wording.

I don't think that any provider is limited to just a specific category or range of diagnoses. In any specialty, it's part of a provider's scope of work to understand not just the disease or problem that they are treating at a particular encounter, but also to take into account other conditions that the patient has or medications that the patient may be taking for unrelated conditions. These conditions may influence care and are appropriately reported by that provider. For example, a psychiatrist treating a patient for depression might note that a patient has CKD because this might influence what medications that the provider may or may not be able to prescribe to treat the depression. But it doesn't mean that because the psychiatrist isn't a nephrologist that they shouldn't be addressing the CKD or that the CKD should not be coded.

So I'm a little confused by your question and by why you'd need to be removing diagnoses from encounter notes or claims. Diagnoses should accurately reflect what's in the documentation, so if the provider in fact documented that they addressed that condition, then it shouldn't be removed. It sounds like maybe your claims are not denied for invalid diagnoses, but for diagnoses that are perhaps not covered or a covered by another payer, is that the case? That's a different issue entirely. Many payers carve out mental health claims to a separate contractor, so if the provider is treating a mental health issue, then those claims often need to be filed differently and are paid under a different benefit (or may not be covered if the patient doesn't have certain benefits or if your provider isn't in the patient mental health network.) You wouldn't remove the mental health diagnosis from the claim just to get it paid if in fact that's what's being treated. It sounds like perhaps someone needs to take a closer look at these denials and to try to understand exactly what is happening. Removing diagnosis codes for conditions that are accurately documented as relevant to the encounter isn't the correct way to resolve denials.

Oh, okay. I guess I was confused by the wording of the denials that one of our billers has been getting and forwarding onto me regarding issues of the provider addressing concussions and also including post concussion syndrome in the list of codes on the claim. It looked exactly like the ones that I get forwarded when symptoms of underlying get conditions get included on a claim - i.e. Lumbar Radiculopathy and Low Back Pain included on the same claim. I was originally told that the F code for post concussion could be included on the claim, but just not primary as the NP in question is still attempting to do - making the F code primary - despite being told not to. Then, I started receiving denials when the F code was even included on the claim. Now that you say that, I should have asked further into that issue. It seems to me that many, if not most, of our patients only have one health insurance plan, so I'm thinking it's probably not that it needs to be paid under a different benefit or filed differently - at least for the patients that only have one health insurance plan, period. How should the claim be handled if the F diagnosis code was not covered under the plan or the provider isn't in the patient mental health network (which I have a hunch that either of those would be the case here)?

Completely agree (as usual) with @thomas7331.
It is certainly not within the job description of a coder to question whether or not a clinician is qualified to address a particular condition. The diagnosis codes should be used for all problems that are documented as addressed.
I do have a sneaking suspicion that claims billed with a primary diagnosis of a mental health issue are being denied as covered under the behavioral health benefit instead of straight medical. Many plans carve out behavioral health to another company.
Depending on the particular situation, you may either need to:
1) correct the claim to reflect the correct primary diagnosis. And keep a lookout in the future to ensure the diagnoses are in the correct order.
2) bill the claim to the behavioral health provider. You may need to credential your provider with another network if they are in fact providing behavioral health services.
Here's an actual real life situation that I happened across recently. Patient saw cardiologist for testing. Patient is also transgendered. The cardiologist claim for echo was submitted F64.9 (gender disorder) primary and R55 (syncope) secondary. The medical insurance denied the claim due to primary diagnosis, and stated it falls under behavioral health. The biller working the denial then submitted the claim to the behavioral health provider. The behavioral health provider denied the claim because it's for an echo. The biller has been bouncing back and forth between the 2 companies, getting denial after denial. The coder needs to correct the order of the diagnoses on the claim. This is why it is helpful for billers to at least have a basic coding understanding.

1. I got a claim denial even when the concussion was primary the post concussion syndrome was secondary with maybe an external cause of morbidity code as the last code listed on the claim. Could that then mean that the post concussion syndrome wasn't covered under the patient's health insurance plan?
2. Bill the behavioral health provider? You mean the NP that's including these diagnoses? What should be done with those claims until the NP gets credentialed with another network because I'm not sure that there's another behavioral health provider involved here.

I want to reiterate the code order. As a behavioral health coder, if the NP is seeing them for a head injury (your example) plus a mental health condition is the mental health condition due to the medical issue? Check for coding sequence and the use of the codes from the F0x.xxx series at the beginning of the mental health ICD chapter.

Yes. I do see that post concussion syndrome is a symptom of the concussion itself, which makes sense to me. I have checked the coding sequence and the concussion is now always Primary and the post concussion either secondary or tertiary, yet I still sometimes get denials related to the diagnoses on the claim. What should be done with the claim if the diagnosis of post concussion syndrome isn't covered under the patient's plan?

 

[carlystur]

Any ideas regarding my last reply?

 

[thomas7331]

Any ideas regarding my last reply?

Your coding should always be driven by your documentation, nothing else. Per the guidelines, the primary code should be "the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided." So if the NP is primarily treating the pain, then code the pain first; if the pathology of the spine, then the code the radiculopathy first; if the post-concussive syndrome and/or behavioral health issues, then that code would go first. Additional codes are sequenced after the primary code if they are conditions that are addressed or affect treatment at that encounter.

The denials are a completely separate issue and should not dictate how you code. Each denial really has to be looked at individually and examined against the payer's policies and the plan benefits in order the determine the correct course of action. Some may need to be appealed, or filed to a different payer, or billed to the patient. It's really the billing specialist's responsibility to make that determination. There shouldn't be a need to involve the coder unless a review is required to determine if the incorrect codes were submitted on the original claim and a corrected claim may be needed.

 

[carlystur]

There shouldn't be a need to involve the coder unless a review is required to determine if the incorrect codes were submitted on the original claim and a corrected claim may be needed.

I think that might be the issue I'm having. I haven't been able to determine whether or not the codes that were submitted were correct based on the denial of missing/invalid/incomplete diagnosis or condition. I'm trying to make sure that there aren't any Excludes1 codes included on a claim, but since I've been told that I cannot remove diagnoses (and thereby the diagnosis CODES) from encounter documentation (which is used to automatically create the claim overnight after the provider locks/signs the encounter note), I have to either remove Excludes1 codes on the claim before it goes out or after it gets denied and they look exactly the same as the ones I was referring to earlier with post concussion syndrome and concussion codes being used on the same encounter and the claim itself.

The doctors are providing their own diagnoses in the Assessment section which include each individual diagnosis code to go with them (we use eClinicalWorks). So, they might put Lumbar Spondylosis with its included diagnosis code M47.816 as one diagnosis and Lumbar Radiculopathy with its diagnosis code M54.16 as a second diagnosis. Now, we know that there is a combination code for Lumbar Spondylosis with Radiculopathy that has the M47.26 diagnosis code, but my providers never use that one unless I'd already added it in a previous encounter for that patient.