Medicare patient seen for gingivitis with history of Mitral Valve Prolapse-Dx code

[jkb77]

Hello! I am hoping for some direction on correct coding of a claim. Patient has Medicare, she came to our physician office because of gum and teeth pain. She was diagnosed with gingivitis. She has a history of mitral valve prolapse, due to this she was put on an antibiotic right away. Medicare does not cover services related to teeth or gums so they denied the claim with primary dx of gingivitis. We added the dx for history of mitral valve prolapse but I feel this should be the secondary diagnosis. Our biller called Medicare and was told as long as the gingivitis diagnosis is on the claim they will not pay. I certainly feel that we need to have the gingivitis diagnosis on the claim. Do you agree gingivitis primary diagnosis, hx of MVP secondary? Looking for reassurance.....

Thank you for your response.

 

[thomas7331]

I agree with you, if gingivitis was the diagnosis given for the presenting problem, that diagnosis should be primary and must be on the claim. Treatment of the teeth and supporting structures, which include the gingivae, is excluded from Medicare coverage except in very limited circumstances, so it sounds to me as though the services were denied appropriately.

 

[jkb77]

Thank you so much for your response!