IPPE diagnosis code for reimbursement?

[jhanmer83]

Recently I've been getting denials for using the Z00.00 Dx code with the G0402 IPPE Medicare code. Medicare always used to reimburse with the Z00.00 Dx code. Should I be using the general condition Dx codes even though that's not the reason the patients are being seen? I called Medicare to find out since their guidelines state that there is no specific Dx code required and was told to look in my ICD-10 book.

 

[Herbie Lorona]

What is the denial reason?

 

[jhanmer83]

What is the denial reason?

The denial is the PR-167 This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Service remark code N30 Patient ineligible for this service.

They pay on the professional claim, but deny on the technical claim. One of my coworkers thinks it's because Medicare doesn't think that should be done in a hospital. The visit was done at a physician's office but falls under the hospital umbrella. Medicare requires all of our claims to split the professional and technical portions.

 

[mitchellde]

What POS is used on the physician claim, what revenue code is used on the facility claim?

 

[thomas7331]

The diagnosis should cover the G0402 on both facility and professional claims. I think the N30 remark code is your clue though - they're saying the patient is not eligible for this benefit. This service is only covered once and must be during the first 12 months of Medicare eligibility. If the patient is outside this, the denial would be correct, and the PR in your denial indicates that you can bill the patient since it is not a covered benefit.

 

[thomas7331]

It is odd though that it would pay on the professional claim though - I almost wonder if your physician claim is accruing the patient's benefit and causing the facility claim to deny?

 

[mitchellde]

That is why I was curious as to the POS on the physician claim and the rev code on the facility claim.

 

[jhanmer83]

The POS on the professional claim is 19 and the rev code on the technical claim is 770.