I have a billing issue that has me puzzled - DX codes are mismatched

[PippiT]

We had a partial denial of a claim where the following codes were not paid, reason being DX codes do not correlate to CPT codes. When I called they said the DX codes are mismatched for coding and reporting, something about lateralizing or bilateral and then using an unspecified code when there is a more specific code available.

99203, 25 the dx codes:
1: M21.6X1 - other acquired deformities of the right foot
2: M21.6X2 - other acquired deformities of the left foot
3: G57..52 - Tarsal Tunnel syndrome, right lower limb
4: G57.51 - tarsal tunnel syndrome, left lower limb

The next two they said 2 or more dx are mismatched and it is not appropriate to report LT & RT bilateral code:

J3301; dx codes:
1. G57.62 - Lesion of plantar nerve, left lower limb
2. G57.61 - Lesion of plantar nerve, right lower limb

J1100; dx codes
1. G57.62 - Lesion of plantar nerve, left lower limb
2. G57.61 - Lesion of plantar nerve, right lower limb

For the office visit, am I to switch the DX codes and put 3&4 in the 1, 2 position an put 1&2 in the 3, 4 position. The provider says there is nothing wrong with it and I cannot find the codes on the CMS inappropriate primary codes list.

For the J codes, do they need to be on separate lines for Rt and lt in order to be paid?

The injections and guided u/s billed with these were all on separate lines (and paid). this is the first time we've ever had this billing issue.

Any insight would be appreciative!!

[kristin]

I see nothing wrong with how this claim was coded/billed, for the denied charges. J codes for injectables do not normally get LT/RT modifiers. The codes on the E/M are all specific enough, and the E/M appears to be unrelated to the injections, so should have paid. Were the injections that already paid on two separate lines with each side's dx, or on one line with a 50 modifier, and both dx's? And is this Medicare, and not Humana MA? Because Humana MA has their own set of goofy rules about using LT and RT, when no other payers require those modifiers.

[PippiT]

It's Amerigroup and the injections were each billed on a line:

20550, LT with the G57.62 DX
20550, 59, RT with the G57.61 DX

I don't even know how to proceed with this one!

And thank you for responding!!

[kristin]

I am not familiar with that insurance's rules, but here is what I *think* may be going on:

1. For the office visit, they may not like the M21.6X1 and M21.6X2, because they don't feel those codes are specific enough to describe WHAT the acquired deformity is on each foot. No other insurance I know has an issue with those two codes, but maybe Amerigroup does. Are there more specific codes to describe what is wrong with each foot?

2. Even though the 20550 paid on two separate lines, the way it was billed, there are a few issues there.
a. 20550 is not the correct code for a plantar lesion injection, the correct code is 64455.
b. It should have been billed like this on one line, following bilateral rules: 64455-50 with G57.61 and G57.62 as the diagnoses, and the price doubled for the one line.
c. Because it was broken out into two lines, with RT and LT, my guess is that the insurance now wants the J codes also broken out onto two lines, with RT and LT modifiers. 

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