Billing > Billing
Z71.9 and 2 Department Billing
TurningPoint:
I have a couple of questions...
I do billing for a Mental Health and Substance Abuse agency.
First, we have clients come in for a Substance Abuse evaluation that do not have a diagnosis. For the reason being, either they received a DUI, got in trouble at school for an alcohol related incident, or is just sent in to have an evaluation done. If these clients do not have any "problems", the counselor will give them a Z71.9 Counseling, Unspecified diagnosis. I have tried submitting this to insurance companies and they say they do not reimburse for this code. That it is too broad and to be more specific. Is there a better diagnosis code that I can present to the counselor to see if it will work?
Edit: I just received another one. A school administrator sent a kid in because he was caught with chew. The counselor gave him a Z71.9. I told her it is going to be denied but we're sending it in anyway.
Second, our agency has two departments, Mental Health and Substance Abuse. Some clients are needed to be seen by both departments. To make it less of a burden we would like to schedule the clients on the same day. We bill with one NPI for the agency. We run into problems billing for this. I have tried using Modifier 59 for a distinct procedural service. I have also tried Modifier XE, Separate Encounter and XP, Separate Practitioner. Neither have worked. Is there another Modifier I could be using. We are trying to avoid getting credentialed with another NPI.
Thank you for your help.
PMRNC:
The insurance carriers won't reimburse that code because many auto carriers or health plans will not pay for any services related to drug or alcohol related illness/injury. Unfortunately you have to be more specific with the diagnosis. Also court mandated services are often not payable either by insurance as well.
I wouldn't try adding modifiers because the doctor is assigning incorrect and possibly fraudulent codes since she may know the carriers are not going to be paying for it. I would try and get her to understand this and assign proper codes. Patient may be responsible for charges.
Michele:
--- Quote from: TurningPoint on November 28, 2017, 12:06:33 PM ---
First, we have clients come in for a Substance Abuse evaluation that do not have a diagnosis. For the reason being, either they received a DUI, got in trouble at school for an alcohol related incident, or is just sent in to have an evaluation done. If these clients do not have any "problems", the counselor will give them a Z71.9 Counseling, Unspecified diagnosis. I have tried submitting this to insurance companies and they say they do not reimburse for this code. That it is too broad and to be more specific. Is there a better diagnosis code that I can present to the counselor to see if it will work?
Edit: I just received another one. A school administrator sent a kid in because he was caught with chew. The counselor gave him a Z71.9. I told her it is going to be denied but we're sending it in anyway.
--- End quote ---
Take a look at icd Z13.89 to see if that applies. It is encounter for screening for other disorder. But that is a broad dx as well.
--- Quote from: TurningPoint on November 28, 2017, 12:06:33 PM ---Second, our agency has two departments, Mental Health and Substance Abuse. Some clients are needed to be seen by both departments. To make it less of a burden we would like to schedule the clients on the same day. We bill with one NPI for the agency. We run into problems billing for this. I have tried using Modifier 59 for a distinct procedural service. I have also tried Modifier XE, Separate Encounter and XP, Separate Practitioner. Neither have worked. Is there another Modifier I could be using. We are trying to avoid getting credentialed with another NPI.
--- End quote ---
Most insurance carriers do not pay for two separate counseling sessions on the same day even if they are with separate providers. You could try to get authorization prior to seeing the patient or else the patient will have to come on separate days. I know it's a pain but if the provider wants to be reimbursed then the patient will have to come in separately.
PMRNC:
--- Quote ---Most insurance carriers do not pay for two separate counseling sessions on the same day even if they are with separate providers. You could try to get authorization prior to seeing the patient or else the patient will have to come on separate days. I know it's a pain but if the provider wants to be reimbursed then the patient will have to come in separately.
--- End quote ---
MANY insurance companies will NOT pay for injury/illness in regards to alcohol or drug related incidents..I should actually say MOST. Most of these incidences result in the patient attributing to this (drugs, alcohol, DUI, etc) and insurance companies will NOT pay. I'm looking at this as the provider KNOWS this because the details of the post preclude to that. In which case ANY other diagnosis is going to create a red-flag with carriers. For example.. patient receives a DUI and part of their criminal proceedings says they must undergo eval and care.. insurance companies (MOST OF THEM) have plans that do NOT include coverage for services rendered as a result of drug/alcohol related ..PROVIDER knows this and is setting a dx code that would NOT include a court ordered eval/treatment and carriers are going to deny as it's not detailed or not. For example, you receive a patient with a court mandated eval...Z02.83 may be the right dx code. MOST insurances are NOT going to cover it and this is why I say the physician insisting on using Z71.9 is going to receive a denial. NOW treatment if continued by the patient may be covered depending on the diagnosis and treatment.
TurningPoint:
--- Quote from: PMRNC on November 29, 2017, 10:02:51 AM ---The insurance carriers won't reimburse that code because many auto carriers or health plans will not pay for any services related to drug or alcohol related illness/injury. Unfortunately you have to be more specific with the diagnosis. Also court mandated services are often not payable either by insurance as well.
I wouldn't try adding modifiers because the doctor is assigning incorrect and possibly fraudulent codes since she may know the carriers are not going to be paying for it. I would try and get her to understand this and assign proper codes. Patient may be responsible for charges.
--- End quote ---
Sorry but this does not make any sense what so ever or maybe I am misunderstanding you.
Insurance carriers won't pay for services related to drug/alcohol related illness/injury? HUH? Medicaid, Medicaid's MCOs, BCBS, and Medicare all reimburse for Substance Abuse Counseling. We were credentialed with these insurance companies for Substance Abuse. In fact, we were just credentialed by a new insurance company for our Substance Abuse department. How do Substance Abuse Counselors get reimbursed then? In addition, we are referred cases from the courts all the time. Many of the clients do have problems but there are a select few who just did something stupid and got caught but they don't have any treatable diagnosis. The only thing you are not able to charge insurance carriers are for a DUI. Any other court-mandated evaluation and treatment are billable that includes both Substance Abuse and Mental Health Therapy.
Then, when you said the Provider is fraudulent billing. That is completely false. The counselor's evaluation determined the client needed no further evaluation. The kid got caught with drinking at a dance and the other with chew and the principals made them get an evaluation. That's the first time they were in trouble and was determined there was no underlying problems.
With the Modifiers, they detail the claim. CMS guidelines have a complete section about Modifiers. HP signifies a doctorate level provider. HO signifies a Master's level provider. U1 signifies a CADC. The HP is reimbursed more than the HO or UI. As a result, our PhD level Provider gets paid more. As he should. HA indicates individual BHIS sessions. HR indicates family BHIS sessions. They have Modifiers for a reason. In fact, one MCO sent us information about the new modifiers to take the place of the 59 Modifier. It's just they deny, deny, deny, and then you have to send them session documentation in order verify. I wanted to know if there was an easier way.
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8863.pdf
--- Quote from: Michele on November 29, 2017, 11:24:28 AM ---
--- Quote from: TurningPoint on November 28, 2017, 12:06:33 PM ---
Take a look at icd Z13.89 to see if that applies. It is encounter for screening for other disorder. But that is a broad dx as well.
--- End quote ---
Thank you for that diagnosis. I will present it to the counselor to see if it fits her evaluation.
--- End quote ---
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