Wiki Removal of Non-covered diagnosis

Create Wiki
A

AR2728

Expert
Messages
325
Location
Perryville, MO
Best answers
0
The scenario here is patient presents and the encounter is documented with a multitude of diagnosis related to the visit, the provider (in this case OBGYN specialty) will always add on Z98.51 Tubal Ligation status when it appropriate status for the patient. We have a contracted state managed Medicaid policy, with a list of non-covered diagnosis, Z98.51 happens to be one of these diagnosis. Now, regardless of this being the 3rd or 12th diagnosis on the claim...the full visit is denied, due to a non-covered diagnosis being listed on the claim.

Is it inappropriate to remove Z98.51, or another non-covered diagnosis, from a claim when the patient is seen a multitude of other reasons? In my humble opinion, to state the full visit is non-covered when all other diagnosis meet medical necessity for a covered visit under that policy, is utterly frustrating.

We are left with two options if unable to remove the non-covered diagnosis. One is to appeal with records hoping that the denial is overturned. The other is to adjust the complete visit due to not obtaining patient signature at tos regarding non-covered.
 
My opinion with status codes is they should be used ONLY if relevant to the visit. And 99.8% of the time, they are not. You could have 12 diagnoses on every visit if you applied all the status codes for their history.
I would not see an issue with removing that code if the patient presented and was treated for other issues. In fact, I wouldn't bill it in the first place. Regardless, it does seem absurd that a carrier would deny payment if the visit was for abnormal menses, or breast mass, or pelvic pain simply because the patient had a tubal ligation in the past.
 
You must log in or register to reply here.
Top