Wiki Submitting two different primary diagnosis codes to primary and secondary insurance

[srouleau]

We submitted a CTA to Medicare and it paid but the secondary denied because of the diagnosis. One of the billers wants me to change the diagnosis so she can re-submit to the secondary for payment. I'm looking for a rule (if it exists somewhere in writing) that we cannot bill different diagnosis codes to the primary and secondary insurance companies. Any help would be appreciated.

diagnosis codes, diagnosis coding

 

[thomas7331]

If one of your payers has some written policy that states they want the claims coded a certain way that deviates from normal coding practices, then in that instance you can code according the payer's policy. Otherwise your claim needs to be coded according to coding guidelines.

In this situation, if it was originally coded incorrectly and needs to be changed, then you would need to resubmit it to the primary payer with the corrections first, and then to the secondary after the primary payer has reprocessed with the new codes. If it was already coded correctly, you can't re-code it incorrectly just avoid the secondary payer's denial. It would be a misrepresentation to send it to the secondary payer with different information than that which the primary payer used to make their payment determination.

I don't think you are going to find anything in writing that addresses this situation, but coding guidelines are clear that you must code all of your claims accurately. If you're coding the same claim two different ways, then one of them is not going to be right.

diagnosis codes, diagnosis coding