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Missing/incomplete/invalid diagnosis code

S

slc112071

Networker
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80
Location
Burkburnett, TX
Is anyone else having issues with getting denials for the use of M06.89 or L40.59 as primary diagnosis codes on office visits or injection services, mainly Toradol?
 
insurance companies are trying to stop the use of unlisted/unspecified dx's.
See if there is an other instead of NOS/unspecified code.
Need to code as specific as possible including laterality
 
With RA or changes from visit to visit if they are seropositive or not. Also, you don't have it in just one joint, it is systemic.
 
I have even used M05.89 specific for seropositive RA and still getting denials for office visits from BCBSTX. Is anyone else having this issue?
 
Hi Slc112071, :)
The insurance company probably wants each body part instead of M06.89. look at the dx block of M06 ...was the RA on hip, knee ,elbow, ankle, feet,shoulder or hand. Also ensure use modifier of RT or LT on claim too along with detailed body area of Rhem. Arthritis documented in the medical notation.
I hope this data helped you.
Lady T(y)
 
TThivierge said:
Hi Slc112071, :)
The insurance company probably wants each body part instead of M06.89. look at the dx block of M06 ...was the RA on hip, knee ,elbow, ankle, feet,shoulder or hand. Also ensure use modifier of RT or LT on claim too along with detailed body area of Rhem. Arthritis documented in the medical notation.
I hope this data helped you.
Lady T(y)
Click to expand...
The thing with that is that RA is systemic. It normally does not affect just one area. I have RA so I know how much it hurts. I had no issues until August and they flipped a switch. I have also been having issues with them paying for Saphnelo. They kept telling me that I could only bill with 2 units.
 
slc112071 said:
Is anyone else having issues with getting denials for the use of M06.89 or L40.59 as primary diagnosis codes on office visits or injection services, mainly Toradol?
Click to expand...
Hi, I work for Fam. Practice and we are now getting denials on Toradol for Humana with Dx M51.16...reason is missing/incomplete/invalid dx or condition. We started receiving denials on our Nov, 2023 claims dos. Wondering If you found any solution to your problem that maybe can help me out. Thanks
 
feiteai@aol.com said:
Hi, I work for Fam. Practice and we are now getting denials on Toradol for Humana with Dx M51.16...reason is missing/incomplete/invalid dx or condition. We started receiving denials on our Nov, 2023 claims dos. Wondering If you found any solution to your problem that maybe can help me out. Thanks
Click to expand...
It is crazy how they flip switches on what they will and won't pay for. There were a couple that I appealed with records and they still refused to pay no matter what. I adjusted those off. There were a couple that I broke it down to exactly where the patients were having pain.
 
In looking at the ICD-10 cross codes for J1885 it appears that in general a pain diagnosis may be the key to getting reimbursed for Toradol. EncoderPro shows the following pain diagnoses that support the use of Toradol.
  • G89.11 - Acute pain due to trauma
  • G89.12 - Acute post-thoracotomy pain
  • G89.18 - Other acute postprocedural pain
  • G89.3 - Neoplasm related pain (acute)(chronic)
While one would assume that a patient with a diagnosis of M51.16 is experiencing pain, the code doesn't indicate if it is chronic or acute. The description of Ketorolac tromethamine (Toradol) indicates it is an NSAID that is indicated for short-term (up to 5 days in adults) management of moderately severe acute pain that requires the analgesia at the opioid level. If your patient's pain isn't acute, the payer may not cover Toradol injections. Also, because M51.16 doesn't mention anything about the type of pain the patient is experiencing you may need one of the above listed G codes to indicate to the payer that the patient has one of these forms of acute pain.
 
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