Wiki Prophylactic mastectomy and oophorectomy

[bbooks]

We are having trouble having a claim accepted (private insurance) for a patient who had both breasts and both ovaries/tubes removed due to a family history of breast and ovarian cancer, and she is BRCA+. The claim has been denied twice. Insurance is not accepting diagnosis codes. It was first submitted with: V84.01, V84.02, then secondly with V16.3, V16.41, V84.01, V84.02. Breasts showed nonproliferative fibrocystic changes and ovaries/tube without pathology.

I suggested changing the codes to: V50.42, V50.41, V84.01, V84.02. Would it help to include the code for fibrocystic breast, 610.1, even though that diagnosis has nothing to do with the reason the surgery was done? It wouldn't do anything for the ovary/tube removal.

Any other suggestions?

 

[KathyJohnson]

The first time the claim was sent out the V50.xx and V16.xxx should've been used. Be careful changing the codes on each submission. This sends red flags to the insurance company. Try submitting supporting documentation for the need for the surgery with the claim.

 

[bbooks]

Thanks, Kathleen. I forgot to mention that the path report was submitted the second time the case was submitted, but thanks for the tip and the reminder! Would you recommend adding the V16.x code to that set of codes I suggested? If so, should it be a primary or secondary code?