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Changing Diagnosis after a denial

  1. #1
    Question Changing Diagnosis after a denial
    Medical Coding Books
    I have a claim that was given a denial code of "not covered under the patients plan" and it was an office consult with a diagnosis of obesity. The patient was being seen for a consult on interest in a bariatric surgery so of course this probably was not covered considering this consult was for a cosmetic procedure. However, most bariatric eligible patients do have other diagnoses that come along with obesity such as diabetes, sleep apnea, reflux, joint pain, etc... So if those things are also mentioned in the patients consult is it wrong (or fraudulant) to make one of other diagnosis the primary diagnosis and rebill the claim as corrected with the insurance carriers form of appeal in order to hope the consult gets paid for the patient?

    I have the same question when it comes to colonoscopies. Patient presents for screening initially but when the scope is done they encounter a polyp which is removed. Can it still be coded as V76.51 primary and 211.3 secondary? Or the patient states they have had some rectal bleeding, or gi symptom and wanted to be checked in a screening...can a screening code
    V76.51 be primary along with other codes as long as all codes are supported in the dictation?

    I appreciate any input on both situations, some people tell me it's considered fraudulant to make these changes after a denial just to get payment and I have thought if it's written down and the changes are supported by dictation than why can't I change them.

  2. Default
    I wouldn't think it was fraud if it is documented in the note.
    I have done it several times with the screening colonoscopy consults. I have had to go back and pull a symptom out of the note.

  3. #3
    Columbia, MO
    If the consult was for obesity, then that is what you use for the first-listed dx. It is incorrect and potentially fraudulent to pull a dx other than what was requested just to get the claim paid, as the chronic problems are not the reason for the consult. As far as the colonoscopy is concerned:
    The coding guidelines have addressed this, and they state that the first-listed dx will always be screening regardless of the findings. You may not use a finding as the first-listed dx when the reason for the exam or test was screening, the finding is considered incidental and as such must go second. If the payer does not cover screening the pt may be responsible for the bill but that is th way it is. The same for the obesity, some payers do not cover visits for obesity and we may not "disguise" the visit as something else to force a payment from the payer. Sometimes patients are responsible.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    I think that if your office does obesity exams on a routine basis, you should have an insurance waiver form letter for the patient to sign where you explain that insurance may not pay for this consultation and they will be responsible for charges. But I definitely agree that it is fraudulent to change a dx just to get the claim paid.

  5. Default Changing diagnoses to avoid deductible
    Can someone please tell me where I can find proof that this is fraud; When a Physician sends an order over with say, shortness of breath for an x-ray, then the patient complains, and a new order for Physical is sent to us (V70.0). I would like to put an end to this....with proof. This has become a major problem for us here, we are constantly being told we "coded it wrong", when the original order is the diagnoses we used. Thanks!!

  6. #6
    Phoenix, AZ
    We get the you coded it wrong all the time. It's usually because the patient has called the insurance company and was told if the office had billed it this way with this diagnosis would have been paid. What the insurance doesn't know is that the purpose of the visit is the screening!
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

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