Author Topic: CPT's vs ICD's?  (Read 2691 times)

dfranklin

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CPT's vs ICD's?
« on: January 10, 2010, 10:46:39 AM »
I keep getting denied with some carriers for cpt 72040 stating the code does not correlate to the listed traumatic diagnosis on the bill.  For this particular one with Mercury, I have  7396,7245,83920,7397...many times they will send a superbill with 6-9 Diag. codes and I always just pick the 1st 4 listed.  How do I know if I should be using the other Diag codes? How do I know if these denials are correct or if there is something I can be doing to fix and resubmit or advise the provider to change etc?  

I also have the similar issue with 98943 (mod 51) where the same few carriers are denying stating the number of spinal/body regions within the diagnoses submitted does not correalate to the nmber of regions described in the procedure(s) reported. Additional supporting clinical documentation is required to re-evaluate appropriate level of manipulation for reconsideration of payment.  This same thing here, I picked the first 4 Diag. codes listed.  Is there a way to know if I should be using other codes? On the same note you can only submit 4 diag. codes how to you get all the codes they are looking for submitted? Or is there no way and you just always have to resubmit with the chart notes/records? Should I always submit the first time with the records or wait for them to ask for them?  I heard you never want to give to much info the first time.

Thanks!

Don

dfranklin

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Re: CPT's vs ICD's?
« Reply #1 on: January 10, 2010, 01:05:08 PM »
I just looked at another one by State Farm.  States documentation submitted does not correspond to the service described in the billed CPT code.  please resubmit correct cpt code per the supporting documentation.  What do I do with these?

It was 98941-AT, 98943-51, 97110 and G0283 (formerly 97014).  ICD's were 7242,71944,7397,7231 (these were the 1st 4 listed.  They paid Zero on all of them noting the reason code above.  Do I presume it was billed correctly and the provider is providing services for Diagnoses that are not reimbursable or do I send the EOB back to the provider asking him to review the Diagnose codes and see if there is a revision he can make?  If you send all these that come back like this with questions...you will have a massive growing pending pile and the provider is going to get piled up on and feel that we are not helping but adding extra work to him....

Any suggestions?

Thanks!

Michele

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Re: CPT's vs ICD's?
« Reply #2 on: January 13, 2010, 09:32:05 AM »
I'm assuming since it is State Farm that it is a no fault claim, and based on that in NY no fault claims for chiropractors are denied with the codes you indicated.  DC's for both WC & NF in NY have to use the codes 99203 for new patient and 99213 for established patient, no matter what services were performed.  I would start there to see if your state has a specific code that they require for DC's.

Michele
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dfranklin

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Re: CPT's vs ICD's?
« Reply #3 on: January 13, 2010, 03:44:54 PM »
Thanks!  I tried to google search and could not really find any information or direction on this. Do you have a more specific place I can look to check on this for the state of PA?

Thanks again!

DMK

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Re: CPT's vs ICD's?
« Reply #4 on: January 14, 2010, 01:49:42 PM »
Ahhhh Chiropractic codes I know!  If you're billing for a 3-4 area adjustment (98941) Be sure to put your 739.x or 847.x codes in the 1st 4 ICD codes.  Example if the patient has cervical, thoracic and lumbar complaints, your 1st code should be the auto accident "E" code then 739.1, 739.2, 739.3, then add any other codes you have.  Only the 1st 4 will show on the claim, so you need 3 areas of complain to bill a 3-4 adjustment.

Michele

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Re: CPT's vs ICD's?
« Reply #5 on: January 14, 2010, 06:02:47 PM »
If DMK's answer didn't help, I would call the carrier (State Farm) and ask them.  They usually are helpful in these situations.  Not always, but I've had good luck.

Michele
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dfranklin

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Re: CPT's vs ICD's?
« Reply #6 on: January 15, 2010, 11:34:45 AM »
DMK so if I am putting the 1st 3 codes (739.x or 847.x) as are of complain for the 98941 what about the other CPT's that were done? Will the 739.x's and/or 847.x's take care of those procedures as well? Or do I need to submit the 98941 with the 739.x's seperately from the other cpt's so I can use the other Diag codes?

Here is the example I used before:98941-AT, 98943-51, 97110 and G0283 (formerly 97014).  Can these co on one claim with the 739.x's supporting them all or do I need to break up the cpt's on to different claims so I can use different codes?

Thanks!

DMK

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Re: CPT's vs ICD's?
« Reply #7 on: January 18, 2010, 12:22:27 PM »
I see there you have an extremity adjustment as well, so put your 739.x codes (at least 3 to bill a 3-4 adjustment), then the extremity dx code (elbow, knee, wrist, arm, leg....whatever area) in the 4th dx slot, then you can pile on as may dx's as there are.  Just know that only the first 4 show on the claim form.  The doctor MOST LIKELY will have sent a short report of the injury to the carrier, they usually request one.  That report can show all of the dx's.  Also, if you get something kicked out, or not paid, call the adjuster on the case.  State Farm is usually fairly easy to get to the adjuster.  Explain that there are more than 4 dx's, if they didn't get a report from the doctor that will help to re-process the kicked out claims and will flag the next claims.

Hope that helps!  State Farm is one of the better payers in our region.  AAA is the best!