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I need help on E/M visit that insurance denied payment

  1. #1
    Default I need help on E/M visit that insurance denied payment
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    I was billing for an E/M visits of 99213 and dx is V26.49. The doctor didn't specify the dx. The patient came in for an educational information about conception or getting pregnant. The insurance denied the diagnosis because it is an infertility code. Is there any way I could code a different code instead of V26.49. When do I use V26.49?

    The patient with her husband came in to discuss how to conceive. The husband was curious if pt is pregnant. Doctor performs urine preg test and result came in, negative. They were trying to know how to get pregnant. So doctor gave a brief educational information about it for less than 20 mins.
    Last edited by coder103; 04-16-2011 at 11:21 AM.

  2. #2
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    Quote Originally Posted by coder103 View Post


    I was billing for an E/M visits of 99283 and dx is V26.49. The doctor didn't specify the dx. The patient came in for an educational information about conception or getting pregnant. The insurance denied the diagnosis because it is an infertility code. Is there any way I could code a different code instead of V26.49. When do I use V26.49?
    What did they talk about exactly? Was he just giving her a biology lesson, or was she trying to find out how to get pregnant, or avoid getting pregnant? The circumstances make a difference...

  3. #3
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    Quote Originally Posted by btadlock1 View Post
    What did they talk about exactly? Was he just giving her a biology lesson, or was she trying to find out how to get pregnant, or avoid getting pregnant? The circumstances make a difference...
    The patient with her husband came in to discuss how to conceive. The husband was curious if pt is pregnant. Doctor performs urine preg test and result came in, negative. They were trying to know how to get pregnant. So doctor gave a brief educational information about it for less than 20 mins.

  4. #4
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    a 99283 is a level 3 ER visit level, I am agreeing with the payer that the dx does not warrent an ER level.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    Quote Originally Posted by mitchellde View Post
    a 99283 is a level 3 ER visit level, I am agreeing with the payer that the dx does not warrent an ER level.
    Correction - its 99213- office visit.

  6. #6
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    Ok so maybe the patient has no benefis for infertility. Not everyones policy covers it. also code the V72.41 for the pregnancy test.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7
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    Quote Originally Posted by mitchellde View Post
    Ok so maybe the patient has no benefis for infertility. Not everyones policy covers it. also code the V72.41 for the pregnancy test.
    If pt has no benefits for infertility can we use a different code like V72.41 first as a primary dx then the V26.49 or change v26.49 to appeal the claim for payment?

  8. #8
    Location
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    Default Do not change Dx to get paid
    It is fraud to change a diagnosis just to get paid.

    If the patient's insurance does not cover fertility counseling that is a benefits issue, not a coding issue. Patient is responsible for the bill.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  9. #9
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    Quote Originally Posted by coder103 View Post
    The patient with her husband came in to discuss how to conceive. The husband was curious if pt is pregnant. Doctor performs urine preg test and result came in, negative. They were trying to know how to get pregnant. So doctor gave a brief educational information about it for less than 20 mins.
    Have you tried V26.41? I could be way off base here, but it sounds to me like this patient doesn't necessarily have a problem with fertility, per se, but they're not sure how to go about getting pregnant...If that's correct, I'd take it a step further and say that this may not be a problem-oriented visit, since there's not necessarily a problem - more of an educational session on family planning advice. I'm hunting for an appropriate CPT to describe it, but so far, the closest I've been able to get is 99078, which won't work (at least, I don't think it will...would a couple count as a group?). I'm also not sure if 'lack of knowledge' counts as a problem, which would make a difference. Anyways...just trying to think outside of the box...
    Last edited by btadlock1; 04-19-2011 at 06:20 PM.

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