Payers tell the patients we should change the diagnosis
Is anyone else having this problem?
Here's the scenario: Our patients (primary care) are given a lab slip in preparation for their upcoming annual physical. The patient has a pre-existing condition. The provider (correctly) puts the diagnosis on the lab slip relative to the patient's condition, because these labs are for surveillance. For example, if the patient is diabetic, and the doc is ordering a HgA1C to be reviewed when the patient comes in for the pe, then the doc would code 250.XX.
Of course, because the patient has a previous diagnosis, and it doesn't fall under routine care, the payer is processing the lab charge against a deductible and co-insurance, and the labs are not being paid at 100% for 'preventive care'. The payers are telling our patients that we coded these wrong, and should use the V72.62...lab work ordered as part of a routine general medical examination. I say, that since the labs are drawn for surveillance of the DM, we should not use the V code, but should code for the reason for the lab....diabetes. Unless things have changed, we can't prevent a condition that is already established, which is the whole point of preventive care! But the payers are telling patients that we are coding incorrectly, and we look like the bad guys. We all know that "they didn't code it right" is secret insurance language for "we don't like you because you're sick, and you have our cut-rate policy".
Is anyone else having this problem? Should I code the V72.62 first, and then the 250.xx? That just goes against the ICD-9 rules, which state you should code the symptom or condition, if it exists, so I'm reluctant to code in order to satisfy coverage requirements.
I would really appreciate feedback! Thanks!
Pam Brooks, MHA, CPC, PCS, COC
Dover, NH 03820
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