Author Topic: Primary diagnosis not payable  (Read 3592 times)

MBiller

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Primary diagnosis not payable
« on: July 02, 2014, 02:48:48 PM »
We're having a disagreement and I'm hoping I can get some sort of documentation one way or another on this issue.  If a primary diagnosis is not payable, is it ok to make another diagnosis the primary diagnosis and leave off the non payable diagnosis.  The assumption here is the other diagnosis is also applicable to the visit and documented. 

PMRNC

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Re: Primary diagnosis not payable
« Reply #1 on: July 02, 2014, 03:56:28 PM »
Can you be a bit more specific? Reason I ask is because I'm sort of having similar issue. I have a psychiatrist who is treating with ADHD, depression and PTSD, Insurance has denied with ADHD because it's specifically NON covered in his policy. I've seen this exclusion in a few other plans. The patient is in process of appealing it along with getting his medication covered. The doctor wants me to bill it changing the dx pointers/primary dx code.  When I do this my PM system is flagging it as edit.. and I'm thinking this can't be done to begin with.. I could override it but not comfortable in doing so. I'm waiting for my client to fax me over the documentation/chart notes.   MY gut is saying we can't do this if we got a denial.    What is your situation?
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rdmoore2003

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Re: Primary diagnosis not payable
« Reply #2 on: July 02, 2014, 04:02:00 PM »
I dont think you can if you have had a denial.  However, if the documentation is not specific on primary diagnosis, I would send the claim in with the documentation and a letter.   It is strange since most insurances go by the first 2 (and sometimes first 3 diagnosis).
Regina

PMRNC

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Re: Primary diagnosis not payable
« Reply #3 on: July 02, 2014, 04:11:28 PM »
Quote
It is strange since most insurances go by the first 2 (and sometimes first 3 diagnosis).

Right BUT if a policy has an exclusion as in my case (charges for services related to ADHD) are NOT covered, they see that dx and they are not paying.
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MBiller

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Re: Primary diagnosis not payable
« Reply #4 on: July 02, 2014, 04:21:00 PM »
Here's my situation.  The physical therapist is stating 078.81 Epidemic Vertigo is the primary diagnosis.  That code isn't added to or system yet, so he couldn't choose it.  They want to first check to be sure it's a payable diagnosis for physical therapy before adding it to the system for any of the therapists to be able to use it.  My thought is that it shoudn't matter if it's payable or not, if it's the primary diagnosis, it should be billed as such.  I'm looking ahead, but thinking the argument on the other side would be that it's ok as long as the other diagnosis they choose is also documented. Before I brought it up, I wanted to get feedback. If I'm wrong, I'm happy to admit it, but if I'm right, I need to be able to show why it's incorrect to not bill that code simply because it's not payable.

shanbull

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Re: Primary diagnosis not payable
« Reply #5 on: July 02, 2014, 04:32:03 PM »
As long as the other diagnoses are documented and already in the claim we will bill with the order flipped. There are several diagnoses that will not be paid if listed as primary for multiple specialties. Behavioral health and acupuncture especially. This does not mean the claims themselves aren't payable and multiple insurers have told us we just need to list something else first and resubmit the claim. We end up having to do this A LOT with new providers at our clinic until they understand the rules of each insurer.
« Last Edit: July 02, 2014, 04:43:11 PM by shanbull »

DMK

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Re: Primary diagnosis not payable
« Reply #6 on: July 02, 2014, 06:45:44 PM »
This is completely not my specialty, but the vertigo is really the only thing a PHYSICAL THERAPIST could treat.  Not ADHD, not depression, not PTSD.  Did the primary doctor refer to P.T. for vertigo?  Then that should be the diagnosis. 

Michele

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Re: Primary diagnosis not payable
« Reply #7 on: July 03, 2014, 11:31:53 AM »
My friend's husband was recently diagnosed as having skeletal vertigo.  I would think PT might help something like that.
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PMRNC

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Re: Primary diagnosis not payable
« Reply #8 on: July 03, 2014, 11:55:12 AM »
Quote
This does not mean the claims themselves aren't payable and multiple insurers have told us we just need to list something else first and resubmit the claim. We end up having to do this A LOT with new providers at our clinic until they understand the rules of each insurer.

In my situation I was told by Aetna we could change primary diagnosis but they of course couldn't tell us it would be paid, she said to mark it as corrected claim. Going to try it. I'm still not comfortable doing it, but I documented everything and we have authorization for the visit.

Quote
This is completely not my specialty, but the vertigo is really the only thing a PHYSICAL THERAPIST could treat.  Not ADHD, not depression, not PTSD.  Did the primary doctor refer to P.T. for vertigo?  Then that should be the diagnosis. 

MBiller had the PT problem.. I sort of stole the post with my ADHD dilemma which I apologize for. At time I didn't know it was PT which is why I asked for more info ;)
Linda Walker
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shanbull

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Re: Primary diagnosis not payable
« Reply #9 on: July 03, 2014, 03:40:28 PM »
Quote
This does not mean the claims themselves aren't payable and multiple insurers have told us we just need to list something else first and resubmit the claim. We end up having to do this A LOT with new providers at our clinic until they understand the rules of each insurer.

In my situation I was told by Aetna we could change primary diagnosis but they of course couldn't tell us it would be paid, she said to mark it as corrected claim. Going to try it. I'm still not comfortable doing it, but I documented everything and we have authorization for the visit.

It does feel strange, I know. We've never run into trouble doing it though because we always make sure the documentation supports it, that really is the most important part. Certainly not a good thing to get into the habit of doing, but it works to straighten out issues where the provider just didn't know not to bill something primary or a policy was changed and we didn't receive the update quickly enough to alert the affected providers before claims started being denied.

Michele

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Re: Primary diagnosis not payable
« Reply #10 on: July 04, 2014, 07:36:59 AM »
Certainly not a good thing to get into the habit of doing, but it works to straighten out issues where the provider just didn't know not to bill something primary or a policy was changed and we didn't receive the update quickly enough to alert the affected providers before claims started being denied.

I agree but we run into it occasionally too where the provider saw a patient for two or three diagnoses and placed them in a certain order.  Then upon realizing that the order made a big difference (to pay or not to pay!) they said that if they had known that they would have put them in a different order.  They state that their notes support it because one issue didn't stand out above the other.  We have also run into some plans that exclude coverage for ADD as well.  In one case the patient had ADHD and behavioral issues.  The provider used both dxs and services were denied.  But like Shanbull said, not good to get in the habit of changing dxs, it may get the provider flagged. 
« Last Edit: July 04, 2014, 07:42:27 AM by Michele »
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