Is this Compliance or Co. Policy

Birdie625

Networker
Messages
63
Location
Holyoke
Best answers
2
Hi, if Ins (M'caid) denies a claim (in total) because 1-dx is not to their liking (unspecified location &/or laterality) and biller then removes the offending dx; resubmits; paid.
It just seems odd a biller can out-right remove a diagnosis, even tho that is part of the reason provider wanted test(s) done. And I strongly say provider(s) need to be taught about specificity/location/lat, etc.. These tests are ordered at a prior office visit then 'pended' until pt shows up to have them done (i.e. blood work for a f/up appt 6-mths later). I've been mind boggled and thought I would throw ? out. Thanks for any time.
 

thomas7331

True Blue
Messages
3,687
Best answers
11
Well, there are two different issues here as I see it. Whether or not a biller can remove a diagnosis is a matter of company policy - if the practice delegates that job function to a biller, then they are within the rights to do so. Hopefully they are delegating work to people who know how to do it properly. But although not illegal, it certain can be risky to have non-coders making coding changes if they aren't properly trained in that area.

But the compliance issue, and the more important question, is whether or not the biller should have removed it. The claim needs to be supported by documentation, and if these are diagnostic tests, then they should be supported by the medical records of the provider who ordered them. Without knowing what was in those records, it's hard to say whether or not the removal of the diagnosis was appropriate. It's usually the case that a claim is denied because it's missing a diagnosis to support medical necessity, not because it has an extra diagnosis on there that causes the denial, so I'm not sure that removing it is that problematic - as long as all the remaining diagnosis codes on the new claim are all supported by the record, I don't think it likely that a payer would have an issue with omitting a code.

And you're correct - if the provider needs education, that a more appropriate response than to simple change the coding without addressing the root of the problem as they will just continue making that same error and causing more denials.
 

Birdie625

Networker
Messages
63
Location
Holyoke
Best answers
2
Thank you for the explanation. Biller 'appears' to be working under a given (flat-out) 'instruction' of "if this, then that" from what I can 'see'. I can tell that some order(s) are done for that specific (offending) dx only and sometimes for that (offending) dx and others as indicated. And totally agree, fix the "reason" for the problem, not just the problem! Thanks again for your time.
 

Orthocoderpgu

True Blue
Messages
1,836
Location
Salt Lake City, UT
Best answers
9
Hi, if Ins (M'caid) denies a claim (in total) because 1-dx is not to their liking (unspecified location &/or laterality) and biller then removes the offending dx; resubmits; paid.
It just seems odd a biller can out-right remove a diagnosis, even tho that is part of the reason provider wanted test(s) done. And I strongly say provider(s) need to be taught about specificity/location/lat, etc.. These tests are ordered at a prior office visit then 'pended' until pt shows up to have them done (i.e. blood work for a f/up appt 6-mths later). I've been mind boggled and thought I would throw ? out. Thanks for any time.
I see this as a coding issue. And changing/removing a diagnosis just to get payment is incorrect. Potential fraud ??? I totally agree with Thomas. I think these denials should be shown to the providers so they can be educated. One of the main reasons of moving from ICD.9 to ICD.10 was so that payers would have better specificity. What's the point if unspecified codes are just going to be omitted? You lost an educational opportunity for sure.
 

Birdie625

Networker
Messages
63
Location
Holyoke
Best answers
2
Thanks for the comment. I agree re: education. This is out of my department and 'things' mgmnt decides on. I was under the impression, these claims would be getting pended and someone would check w/dr for further clarification re: loc/lat before a bill even went out. A big problem I see is that the offending dx being used is M25.50 and users have been able to change the true 10-description to fit their needs; hence they changed words to "Arthralgia" = which it is, but they dont realize that the 10-code is not a one-code-fits-all. Another example M25.551 - users have changed to Pain in "bilat" hip. Augh! And yes brought up to mgmnt, etc, etc. And "maybe" mgmnt is doing something re: education. Wont hold my breath. Thank you for the comments.
 
Top