Wiki Medicare LCD Appeal and Diagnosis Coding

[christiwithani]

I have a patient's claims that have been denied by Medicare due to the diagnosis not being on the LCD. I submitted a first level appeal that subsequently denied and am in the process of submitting a second level of appeal. I asked my provider to write a letter to support medical necessity; the patient was treated with IMRT, and now he is asking if we can just change the diagnosis code and rebill the claims. My understanding is that if there is a true clerical error I could have made the correction but I worry if I do that now, it will raise some red flags. Thoughts?

 

[momo2]

I've just accepted a compliance position but remember the LCD's. My opinion would be that if he selected the incorrect diagnosis, then he probably needs to support it with an attestation to the progress note original DOS. If the documentation doesn't support the new code then I wouldn't think it would stand up. Just my 2 cents.

 

[Robyn07]

I completely agree with Momo2. Changing a diagnosis code really isn't that simple, especially if the documentation doesn't support it.

 

[sls314]

I have a patient's claims that have been denied by Medicare due to the diagnosis not being on the LCD. I submitted a first level appeal that subsequently denied and am in the process of submitting a second level of appeal. I asked my provider to write a letter to support medical necessity; the patient was treated with IMRT, and now he is asking if we can just change the diagnosis code and rebill the claims. My understanding is that if there is a true clerical error I could have made the correction but I worry if I do that now, it will raise some red flags. Thoughts?

What was the diagnosis code submitted on the claim?

What verbiage is listed for the diagnosis on the Treatment Planning document? (Not the diagnosis code the physician selected, but the actual diagnostic verbiage used by the physician.)

Are you billing for the facility or physician?

The Treatment Plan is the provider’s prescription for radiation therapy. It tells what type of radiation treatment was ordered and what condition it was ordered for. This document would be completed at the beginning of the course of therapy, but it should be applicable for the entire course of treatment. (Unless there was a change in patient’s condition that required a new plan.). Rad Onc is somewhat unique in that there isn’t a physician note for every DOS. You’ll have your consult, your treatment plan, and your note every 5 fractions.

All of those documents should clearly indicate verbally why the IMRT was ordered.