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Primary diagnosis not payable

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MBiller:
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:
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?

rdmoore2003:
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).

PMRNC:

--- Quote ---It is strange since most insurances go by the first 2 (and sometimes first 3 diagnosis).
--- End quote ---

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.

MBiller:
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.

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