Wiki Viva Health Claim Denial

[khartoum1900nile@aol.com]

I have a claim where Viva Health is denying due to: diagnosis(es) billed are inappropriate for pos. The given diagnosis for this date of service is:
I10,E78.5,E03.9,I63.9,E55.9,J02.9 and R73.09. The patient came in for an office visit and then had a flu shot same day. Why would this claim be rejecting. Any help would be appreciated.


Bethany K. CPC,CPB

 

[NRCutcher21]

I have a claim where Viva Health is denying due to: diagnosis(es) billed are inappropriate for pos. The given diagnosis for this date of service is:
I10,E78.5,E03.9,I63.9,E55.9,J02.9 and R73.09. The patient came in for an office visit and then had a flu shot same day. Why would this claim be rejecting. Any help would be appreciated.


Bethany K. CPC,CPB

Hey, I know this is an old thread, but I am having this same issue did you ever find out how to fix it or what the issue was? Thanks.

Natalie C. , CPC

 

[sls314]

Hey, I know this is an old thread, but I am having this same issue did you ever find out how to fix it or what the issue was? Thanks.

Natalie C. , CPC

I can tell from looking at the original post that her issue was using I63.9 in a provider office setting. Unless the patient was literally having a stroke in the office during the exam, it's not an appropriate diagnosis code for POS 11.

What diagnosis codes are on your claim?

 

[NRCutcher21]

Hey ok that kind of makes sense. my claim has G35, F32.0, I26.99 and M25.512 billed with 99214. I was thinking the I26.99 was causing the issue but I wasn't completely certain.

Natalie C. CPC

 

[khartoum1900nile@aol.com]

Never had a chance to get this corrected.

 

[sls314]

Never had a chance to get this corrected.

The I63.9 caused your issue - it shouldn't be billed in POS 11. You wouldn't use an I63 code for a provider office visit, as that is an acute stroke code. (Rare exception could be if the patient was actually having the acute stroke in the office and taken to the hospital from the office.)

If a patient is having residual effects after a stroke, you'd use a code from the I69 category to specify what type of complication/sequelae the patient was experiencing.

That's how you should code it for all payers, but here's a document specifically from Viva Health that spells it out as well:

https://www.vivahealth.com/Download.aspx?ID=32861&Type=doc

Page 1 - ICD-10-CM Documentation Guidelines

• Strokes: Once the acute phase is over and there are NO residuals, document as “HISTORY of CVA”.
o Do not bill acute stroke codes in the office setting.
• For residuals from a stroke, document as residuals/Late Effects/Sequelae due to the CVA (H/o CVA w/Hemiplegia).

Page 5 - Stroke and Late Effects of Prior Stroke

One of the most common coding errors seen in chart audit is the assignment of an acute stroke code when the coder is actually trying to code for the residual conditions left behind by a prior stroke. Acute stroke is only coded during the initial episode of care. After the initial episode, Late Effects or Personal History codes should be used, and the physician should document the patient record accordingly.

 

[sls314]

Hey ok that kind of makes sense. my claim has G35, F32.0, I26.99 and M25.512 billed with 99214. I was thinking the I26.99 was causing the issue but I wasn't completely certain.

Natalie C. CPC

Looking at the other codes on your claim, I suspect you're right about the I26.99.

There are a few different Coding Clinic citations for I26.99. I don't have access to a current subscription to look up the references right now, but if you do (or know someone else who does) it might be worth looking up to get a definitive answer.