Author Topic: Help!  (Read 1209 times)

digitalfusion

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Help!
« on: July 17, 2010, 04:42:46 PM »
I have a sticky situation and maybe you can help me!
In april I had to go to get a cardiac cath done, and the claim was rejected because of coding
My insurance doesn't cover congential conditions (I have a Ventricular Septal Defect (a congenital heart condition)).
I went this year for an echo (have to do it every year) and when they did the echo it read pulmonary hypertension, however the VSD was very small, and the heart was normal in size etc etc.  only a reading of pulmonary hypertension was resulted from the echo. Anyway, the doctor wanted to verify it and did a cardiac catheterization to check all the pressures, and also do a shunt test to see how big the VSD truely was (it was very minor on echo, almost didn't catch it).
In any case, they coded all my charts with VSD for the procedure.  I'm not expecting to get them to cover the initial echo because that is truly related to my VSD being that it is a yearly follow up thing, but I think that the cath should be covered since it was done to rule out pulmonary hypertension, but it really wasn't done for the VSD.  I would like to say that sure the VSD was there, but it was so insiginificant that they believed the HTN was due to other causes.  After the cath, it was found that all my pressures were normal and the vsd was minimal, so what would be an appropriate code for that procedure?
I started receiving bills ($18,000) total right now! I sent a letter to the insurance company explaining that this procedure was done to check for the cause of the pulmonary hypertension and that the VSD was so small it could not be related to it.  However they replyed back that the claim had VSD as the diagnosis, and because of that the denial must remain since it is a congenital condition which is not covered by the plan.

Sabrinakayb

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Re: Help!
« Reply #1 on: July 17, 2010, 07:21:59 PM »
What you will need to do is have the ordering physician to do an addendum on the code set that was used. He or she, will also need to send in their notes explaining the reasoning behind the second test. They will need to be very specific, in stating they were aware of the VSD, but the second one was to find the source of the HTN. Hopefully, you have a good relationship with this office and they will comply with your request. Otherwise, you will end up paying for this. Hope this was helpful.

Best of luck,

Sabrina

oneround

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Re: Help!
« Reply #2 on: July 26, 2010, 11:53:54 AM »
df, by chance do you know what codes the coders used and the order that the coded?  Two words that you quoted are standing out to me.  'rule out' and 'due to'


Rule-Out Diagnosis
There are no rule-out diagnoses listed in the ICD.9 book. Rule out diagnoses are not billable.
If the diagnosis documented is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or
“rule out”, then the codr must code for the associated signs and/or symptoms. Or, they may need to use the personal or family history codes to indicate the reason for the medical services.
Codes for Symptoms, Signs, and Ill-defined Conditions

I would coded the signs and symptoms for the HT if the documentation supported it.

Codes for symptoms, signs, and ill-defined conditions are not to be used as principal diagnosis when a
related definitive diagnosis has been established.

last poster gave good advice.  I would have the codes reviewed


Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare

Sophrosyne

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Re: Help!
« Reply #3 on: May 02, 2013, 01:30:57 PM »
If the diagnosis documented is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or
“rule out”, then the codr must code for the associated signs and/or symptoms. Or, they may need to use the personal or family history codes to indicate the reason for the medical services.
Codes for Symptoms, Signs, and Ill-defined Conditions

I would coded the signs and symptoms for the HT if the documentation supported it.

Would these signs and symptoms codes go in box 21 on a cms-1500, same as a diagnosis?
My boss, a clinical psychologist, recently performed an evaluation, but was unable to justify a diagnosis. He ruled out ADHD and learning disability. Not sure if it's possible to code this. I am unaware of any "signs and symptoms" codes that would apply for mental health billing, but then again, I am not a professional biller! Any advice is much appreciated.