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Dementia and office

  1. Default Dementia and office
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    I am currently being denied by a few insurances but Healthnet is the primary one for an office visit by a neurologist.

    The patient see's the neurologist to map how progressed dementia is so the cpt is 99213 and the icd 9 supporting is 294.10.

    The denial reads that its a manifestation code and cannot be billed alone or just a flat non-covered but this is the only reason the neuro see's those patients, has anyone else ran into this issue or have any idea's of why they are denying? I tried calling a service rep but they weren't very helpful.

  2. #2
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    Sioux Falls South Dakota
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    Quote Originally Posted by shadith4 View Post
    I am currently being denied by a few insurances but Healthnet is the primary one for an office visit by a neurologist.

    The patient see's the neurologist to map how progressed dementia is so the cpt is 99213 and the icd 9 supporting is 294.10.

    The denial reads that its a manifestation code and cannot be billed alone or just a flat non-covered but this is the only reason the neuro see's those patients, has anyone else ran into this issue or have any idea's of why they are denying? I tried calling a service rep but they weren't very helpful.
    The note under 294.1 specifically says to code first the underlying disease. So, when coding 294.10, it is a manifestation and you need to code the underlying disease such as Alzheimer's, Parkinson's, etc. Although your provider is seeing the patient for the dementia, that doesn't change the guideline to code the underlying disease first.

    As another example of this; a patient with diabetic retinopathy (362.01) goes to see the opthalmologist; although not treating the diabetes, per the instructions/note with code 362.0, you would code first the diabetes (250.5X).

    I hope this helps.
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  3. Default
    Thanks, that helps alot. I knew it needed the underlying disease but the provider is arguing with me that they only see the patient for that one reason. That gives me another way to explain what is needed.

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