Question Order of ICD-10 Codes

ch81059

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Ethel, LA
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I have a claim for a patient that was denied for primary dx not covered under the plan. Patient's chief complaint was bilateral jaw pain. He was diagnosed with TMJ but while he was there, tests were ordered for his hypertension and he received a flu vaccination. The medical plan doesn't cover TMJ because it's considered a dental issue. Will this need to be transferred to self-pay as the EOB suggests or can the order of the dx codes be changed since covered conditions were also treated? Documentation from chart is listed below:


Patient was seen today for facial pain.

Diagnoses and all orders for this visit:

1. TMJ (temporomandibular joint disorder) (New)​
      
- Refer to dentistry for oral appliance to be worn nightly
-     methocarbamol (ROBAXIN-750) 750 mg tablet; Take 1 tablet by mouth nightly as needed for up to 30 days., Starting Mon 9/16/2019, Until Wed 10/16/2019, Normal

2. Essential hypertension (Controlled)​

-     CBC and differential
-     Comprehensive metabolic panel
-     Lipid panel
-     TSH
-     Urinalysis with microscope
-     Microalbumin Random Urine
      -     Home BP log: Notify office if readings are greater than 140/90
      -    DASH diet

3. Need for vaccination​

-     High-Dose 0.5 mL (PF) Influenza Virus Vaccine

4. Class 2 severe obesity with serious comorbidity and body mass index (BMI) of 35.0 to 35.9 in adult, unspecified obesity type (HCC)​
 BMI Follow Up plan:
High BMI: BMI Follow Up Plan documented in the Care Plan or Problem List overview notes.
 
No there is nothing you can do. You cannot disguise the reason for the encounter as something the payer will cover when it is really something else. Your provider could have decided the facial pain was more dental than medical and had the patient see an oral surgeon who would make the diagnosis. However that is not how it happened. You can try to appeal the denial and try to convince the payer this was more medical than dental, however that is the best it will get.
 
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