Wiki physical therapy coding advice R42

[awhite@galaxybraincenter.com]

I'm new to this coding stuff and could really use your input/advice: for Physical therapy professional office we have billed out 3 visits cpt codes 97161, 97112, and 97110 to BCBS of Michigan and have gotten denials for 2 so far 9/5/24 hasnt came back yet but will deny. these were denied Due to Diagnosis codes R42- Vertigo( dizziness and giddiness) not being a covered code. Client has a lingering dizziness and wooziness following a viral infection. She reports an ear infection in June following a covid infection, history of concussion 12 years ago. We are looking for a covered dx code we can use and I want to make sure we bill this out correctly and get paid. I was able to look up specific dx codes in the benefit explainer for this client's plan. code R42 showed NOT covered, and H81 code( vertigo) NOT Covered, Z87.820 Personal history of traumatic brain injury NOT covered. So I thought because this client had vertigo due to covid related, I did find a code U09.9 Covid- Post covid-19 condition unspecified that is a covered code. Is this something we can use for this client as primary? or do you have another code we possibly can use or should say can look up in the benefit explainer to see if its a covered dx?

diagnosis codes, diagnosis coding

 

[sls314]

I'm new to this coding stuff and could really use your input/advice: for Physical therapy professional office we have billed out 3 visits cpt codes 97161, 97112, and 97110 to BCBS of Michigan and have gotten denials for 2 so far 9/5/24 hasnt came back yet but will deny. these were denied Due to Diagnosis codes R42- Vertigo( dizziness and giddiness) not being a covered code. Client has a lingering dizziness and wooziness following a viral infection. She reports an ear infection in June following a covid infection, history of concussion 12 years ago. We are looking for a covered dx code we can use and I want to make sure we bill this out correctly and get paid. I was able to look up specific dx codes in the benefit explainer for this client's plan. code R42 showed NOT covered, and H81 code( vertigo) NOT Covered, Z87.820 Personal history of traumatic brain injury NOT covered. So I thought because this client had vertigo due to covid related, I did find a code U09.9 Covid- Post covid-19 condition unspecified that is a covered code. Is this something we can use for this client as primary? or do you have another code we possibly can use or should say can look up in the benefit explainer to see if its a covered dx?

What does the documentation say? What does the prescription from the ordering physician say? You have to code based on the documentation.

Did the ordering physician or the physical therapist clearly document that the patient's vertigo was due to COVID-19 complications? You as the coder cannot make that determination - you can only go by what the clinical staff has documented.

Unfortunately, you can't look for something on the list and try to make it fit to get paid, if the clinicians didn't clearly document the order and documentation that way. I understand the impulse, because you're just trying to be helpful and make sure the patient doesn't have to pay out of pocket or the provider have to eat the charges. However, we can only code what the clinicians documented.

Were benefits verified prior to treatment beginning? Was there any prior authorization obtained? Even if prior authorization was not required, there still should have been a benefit verification.

It's all a learning experience. The good news is that now you (or whoever verifies benefits in your office) know to confirm coverage with the insurer next time a patient comes in with an order for physical therapy for vertigo.

diagnosis codes, diagnosis coding

 

[Pam Warren]

Although I can understand why you'd want to find a 'covered diagnosis code' in order to get paid, you do need to report the reason why the patient received treatment. Submitting a diagnosis code that isn't the true reason for the visit is a violation of the False Claims Act.
Unless the dizziness has been documented by the provider as a late effect of the Covid infection, you wouldn't add the U09.9 as a secondary diagnosis (because the appropriate way to code the post-Covid condition is with the R42 primary and the U09.9 secondarily.) So I'm not sure that's going to help you.

diagnosis codes, diagnosis coding

 

[awhite@galaxybraincenter.com]

What does the documentation say? What does the prescription from the ordering physician say? You have to code based on the documentation.

Did the ordering physician or the physical therapist clearly document that the patient's vertigo was due to COVID-19 complications? You as the coder cannot make that determination - you can only go by what the clinical staff has documented.

Unfortunately, you can't look for something on the list and try to make it fit to get paid, if the clinicians didn't clearly document the order and documentation that way. I understand the impulse, because you're just trying to be helpful and make sure the patient doesn't have to pay out of pocket or the provider have to eat the charges. However, we can only code what the clinicians documented.

Were benefits verified prior to treatment beginning? Was there any prior authorization obtained? Even if prior authorization was not required, there still should have been a benefit verification.

It's all a learning experience. The good news is that now you (or whoever verifies benefits in your office) know to confirm coverage with the insurer next time a patient comes in with an order for physical therapy for vertigo.

thank you so much!!! yes this is learning for me and VERY new to this, and i appreciate this so much!!!!!! this helps me alot!!!

diagnosis codes, diagnosis coding

 

[awhite@galaxybraincenter.com]

Although I can understand why you'd want to find a 'covered diagnosis code' in order to get paid, you do need to report the reason why the patient received treatment. Submitting a diagnosis code that isn't the true reason for the visit is a violation of the False Claims Act.
Unless the dizziness has been documented by the provider as a late effect of the Covid infection, you wouldn't add the U09.9 as a secondary diagnosis (because the appropriate way to code the post-Covid condition is with the R42 primary and the U09.9 secondarily.) So I'm not sure that's going to help you.

thank you so much!!! yes this is learning for me and VERY new to this, and i appreciate this so much!!!!!! this helps me alot!!! appreciate this info, any inof is helpful in doing this right!!!

diagnosis codes, diagnosis coding