Wiki Insurance denying unspecified diagnosis?

[gayla_atkins@live.com]

We have a local insurance plan that is denying ALL unspecified diagnosis. We see a lot of COPD in our geriatric practice and our J44.9 is also being denied. This patient is not experiencing acute exacerbation or lower respiratory infection. Is there alternate diagnosis that can be used?

 

[thomas7331]

Unspecified diagnosis codes are valid and it is inappropriate to deny these across the board. I can understand denying a code for which a more specific code is something that could reasonable be expected to be documented in the record (e.g. requiring a code for the left or right eye or leg rather than unspecified), but there are many cases where a provider cannot be more specific in the diagnosis without doing additional diagnostic work. CMS has actually published guidance to this effect. It would not be correct to require the patient to undergo additional and/or unnecessary testing solely for the purpose of being able to submit a more specific code. If I were in your place and saw this happening, I would escalate this very quickly with the practice manager and your payer representatives.

 

[kdlberg]

I've been seeing this happen with more payers. And yes, it's great if you can get more specific--I see those opportunities when I'm coding--but sometimes, you can't.

I would contact the insurer and see what's up.