Wiki Medical necessity for Dx F31.70

[Harmonyunited]

Hi,

Could you please help me with Dx F31.70 as not meeting Medical necessity (denial) for payor Medicare part-B. Give me a suggestion about this kind of denial.

Thanking you.

 

[sls314]

Hi,

Could you please help me with Dx F31.70 as not meeting Medical necessity (denial) for payor Medicare part-B. Give me a suggestion about this kind of denial.

Thanking you.

What services were billed? (CPT/HCPC codes)

F17.70 is the code bipolar disorder currently in remission, most recent episode unspecified. That is the least specific code in the F17.7- range. In general, payers do prefer more specificity when appropriate.

In the F17.7- code category, there are codes that are more specific on whether the remission is full or partial. There are also codes that are more specific on whether the most recent episode was hypomanic, manic, depressed, or mixed.

If the documentation supports a more specific code, that should be used instead of the unspecified code.

If the provider's documentation didn't demonstrate specificity, then that may be why the payer is questioning the medical necessity of the service.

(It's hard to say without knowing the CPT/HCPC codes billed on the claim. There may be an NCD/LCD or other CMS policy that could shed some light on the denial, beyond just the unspecified diagnosis.)

 

[CBLENNIE]

I mostly agree with Susan's response, except that the code listed in the original post was F31.70, not F17.70.

In addition to Susan's questions regarding what services were billed, what are the specific denial reason code(s) or message(s) from Medicare and who is your Part B MAC?

 

[ckeeney]

I checked the LCD for the Florida MAC and F31.70 is not covered for therapy services (https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57520). If this was an E&M service the LCD would not apply. It may be that the code states "in remission" which may not justify medical necessity.

 

[TThivierge]

Hello Harmonyunited,
F31.70 is Unspecified Bipolar DO in remission. There are about 8 more Bipolar DO give more documentation....talk to provider or see if any of these descriptions of depression, mixed mood, maniac, remission, in documentation. Most payers do not want to cover unspecified illness when another dx can give more details on patient health.
I hope helped you
Lady T

 

[sls314]

I mostly agree with Susan's response, except that the code listed in the original post was F31.70, not F17.70.

In addition to Susan's questions regarding what services were billed, what are the specific denial reason code(s) or message(s) from Medicare and who is your Part B MAC?

That's what I get from typing on my phone! I didn't even see that I hit the wrong number.

I did type the descriptions for F31.70 - just made a typo in the numbers on the code. Whoops!

 

[Harmonyunited]

Hi all, thank you so much for your suggestions, it really helps me a lot and appreciated!