Unlisted diagnosis codes could lead to denials

May 10, 2017

Q: We have recently been receiving patient complaints for procedure claim denials. These used to get paid, and our physicians haven’t changed how they are coding. Can you help?

Q: We have recently been receiving patient complaints for procedure claim denials.
These used to get paid, and our physicians haven’t changed how they are coding. Can you help?

A: Take a look at the diagnosis code(s) that your physicians are using. If they are assigning unlisted codes to support procedures, this could be the issue. The first year of ICD-10 coding didn’t yield too many denials based on unlisted codes because providers were given a grace period to get up to speed with the expansion of codes, and payers hadn’t instituted their claim edits yet.

So now that we are outside that first year, you will see denials increase when unlisted codes are used.

Talk with your physicians and reinforce the importance of coding diagnoses to the highest level of specificity. This will not only increase revenue but will also cut down on patient complaints.

Q: For transitional care management (TCM) services, should our contracted nurses determine when the patient should be scheduled for their required 7- or 14-day face-to-face visit?

A: It’s important to remember that TCM services are “incident-to.” That means that the physician-or non-physician practitioner (NPP)-needs to supervise and direct the services performed by the licensed clinical staff. Therefore, the physician should be consulted to determine whether or not the patient is a candidate for TCM services. 

 

It’s important that the physician direct the nurses with medication refills, coordination of community services that the patient may need (prior to and after the visit), and any education that the patient might need.

Example:  A patient was admitted to the hospital for vertigo. He went through a series of tests that ruled out any cardiac, respiratory or neurologic issues, so he was discharged with the diagnosis of vertigo that is stable. The patient is instructed to follow-up with his primary care physician.  

Should this patient be considered for TCM services? 

There are a few things to take into consideration.

  •   The physician/NPP should make this determination, not a licensed practical nurse (LPN).
     

  •   What qualifies a patient for TCM services is the fact that he/she was in the hospital. So the hospital diagnosis needs to be taken into account when determining if the patient should receive TCM services.  
     

  •   TCM services follow the evaluation and management (E/M) guidelines for determining medical decision making (MDM). While the level of MDM for the code level billed is determined at the face-to-face visit, MDM needs to also be taken into account when determining whether or not the patient is TCM-eligible. In the example, the patient wouldn’t meet the minimum requirement of moderate MDM, and therefore should not be considered for TCM services. 
     

  •   If your network has an auditing protocol in place, the E/M guidelines are routinely taught to physicians. So the physician can determine the possible level of MDM and direct the LPN whether the patient should be scheduled for an appointment within seven or 14 days.