I am having trouble with using Z60.0 - Z65.8 as the primary diagnosis. I know these have the Medicare code edit symbol (Unacceptable principal diagnosis per Medicare Code Edits) on them but I am using them for Medicaid only claims. Would that symbol apply or should I dispute with the payer?
Medicaid allows them in the manual. They are for outpatient behavioral health services.What was the reason for the encounter?
Those code ranges are generally meant to provide additional information about the patient's risk factors, rather than be the purpose of the entire encounter.
The only time I'd use one of those codes as primary would be if Medicaid (or another payer) had a payer-specific rule that said to use the code as primary for a specific service.
Medicaid allows them in the manual. They are for outpatient behavioral health services.
Yes, it's for Missouri Medicaid. It is being denied for "Principal Diagnosis invalid. Code cannot be used as principal DX". These claims should not require a precert as they are CCBHC claims. I can absolutely look into if there is a time limit or if I am wrong about the precert. These are managed care medicaid so I think I will reach out to the rep if that doesnt pan out. We aren't seeing denials for these codes with other MCO's or straight medicaid claims either as far as I know.Is this for Missouri Medicaid? (Each state's Medicaid program has it's own billing guidelines and those can vary widely from state to state.)
I took a quick glance at the Missouri Medicaid provider manual for Behavioral Health Services, under the assumption that we're talking about Missouri Medicaid. Before disputing with a payer, it can be helpful to narrow down why the claim denied and if there was something that could have been billed differently instead vs needing to be appealed.
What is the denial reason or remark codes being given?
Is this for adult or child services? It looks like for adults there's a precertification limit of 10 hours per rolling year for Z-code diagnoses. (p 29 of the manual). If these are adult patients, is it possible they've exceeded the 10 hour limit per rolling year?
Was precertification obtained? If so, does the billed diagnosis match the precert diagnosis?
Those are just a few questions off the top of my head after looking at the MO Medicaid manual. I'd be especially curious to hear the remark codes being given on the denials.