Wiki Can you change a lab diagnosis after getting a denial?

Create Wiki Sort by votes
M

mrsrobinson525

Contributor
Messages
17
Location
Black Mounatin, NC
Best answers
0
I'm a newer coder and I work for a smaller private practice. I normally review charges, but recently I've been asked to help with denials.

Our providers code their own charts and we have a lot of lab denials. I'm hoping someone can give me some information and references I can provide to my management team.

If a lab was denied for non-covered diagnosis:

-I've been told to check to see if there is another covered diagnosis listed in the chart note, and if so, rebill with this diagnosis.
-If there are no covered diagnosis codes in the chart note, I've been told to check the patient's problem list, and if I find one, ask the provider to add a late entry/correction for that code.
-If nothing is covered in the patient's chart or problem list, I've been told to send back the CMS approved diagnosis list to see if the provider can find anything that is appropriate for the patient.
If they find a diagnosis, the provider would add a late entry/ correction to the chart note and we would rebill with this.

Is this process correct?

The first two steps seem reasonable, but I don't know about sending the approved diagnosis list. This seems like we are changing the diagnosis to "get paid".


Can someone please give me references? I don’t want to do anything incorrectly and jeopardize my accreditation.



Thanks so much!
 
0
I've been doing lab billing for a while now and providing the approved diagnosis list is something that we do frequently. It's an education tool more than anything to let providers know that "Hey, we know you're doing the test for X, Y, or Z, but according to (insert payer here) that diagnosis code isn't a reason to do the test. Do you have any other reasons you did the test? If not, that's fine. However, for the future, these are the only 'approved' reasons for those tests so keep that in mind when ordering." I do billing for an independent laboratory that is nationwide and I'm the Medicaid/MCO expert there; I frequently have to have sales provide education to the clinics about coding for their tests. I have some providers that only like to send Z codes that require additional diagnoses. 🤦‍♀️
 
1
mrsrobinson525 said:
I'm a newer coder and I work for a smaller private practice. I normally review charges, but recently I've been asked to help with denials.

Our providers code their own charts and we have a lot of lab denials. I'm hoping someone can give me some information and references I can provide to my management team.

If a lab was denied for non-covered diagnosis:

-I've been told to check to see if there is another covered diagnosis listed in the chart note, and if so, rebill with this diagnosis.
-If there are no covered diagnosis codes in the chart note, I've been told to check the patient's problem list, and if I find one, ask the provider to add a late entry/correction for that code.
-If nothing is covered in the patient's chart or problem list, I've been told to send back the CMS approved diagnosis list to see if the provider can find anything that is appropriate for the patient.
If they find a diagnosis, the provider would add a late entry/ correction to the chart note and we would rebill with this.

Is this process correct?

The first two steps seem reasonable, but I don't know about sending the approved diagnosis list. This seems like we are changing the diagnosis to "get paid".


Can someone please give me references? I don’t want to do anything incorrectly and jeopardize my accreditation.



Thanks so much!
Click to expand...

Oh my.

The first one is reasonable. If another diagnosis is documented in the chart note, it can be used to bill. That's the key - if it is already appropriately documented and just didn't make it onto the claim for whatever reason.

The last 2 points are problematic. You should not send a list of payable diagnoses so the provider can find something that will be payable. You should not be asking the provider to add specific diagnoses to a claim for payment purposes.

If the documentation is unclear or insufficient, you can query the provider. However, be sure to follow compliant query processes.

Here are a couple of links to help you understand what is and is not a compliant query. (I tried to find a few quick links to free resources rather than subscription newsletters—if I find more, I'll add them.)



Excerpts from the above linked ACDIS PDF:

page 2
Queries must not contain any information about their impact on reimbursement. According to Guidelines for Achieving a Compliant Query Practice, “a leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure.” The practice brief stresses the importance of not leading the provider.

page 14
Leading query example
Note: The following is an example of a leading (i.e., noncompliant) query:
Your patient, Mr. Jones, has a past medical history of CAD, CHF, and COPD. Please document these conditions during the encounter today. Thank you.





There are also some great podcasts that cover compliance topics, including CodeCast by Terry Fletcher, The Compliance Guy by Sean Weiss, and Coding with Christine Hall. I know each of those podcasts likely have episodes relevant to your specific question, but I'd have to hunt for the specific episodes later. In the meantime, if you're inclined to browse their episode lists on your own, you can do that too!
 
0
andersona1229 said:
I've been doing lab billing for a while now and providing the approved diagnosis list is something that we do frequently. It's an education tool more than anything to let providers know that "Hey, we know you're doing the test for X, Y, or Z, but according to (insert payer here) that diagnosis code isn't a reason to do the test. Do you have any other reasons you did the test? If not, that's fine. However, for the future, these are the only 'approved' reasons for those tests so keep that in mind when ordering." I do billing for an independent laboratory that is nationwide and I'm the Medicaid/MCO expert there; I frequently have to have sales provide education to the clinics about coding for their tests. I have some providers that only like to send Z codes that require additional diagnoses. 🤦‍♀️
Click to expand...

Using a list as an educational tool for future claims is fine.

However, in her original post, it sounds like she's being told to send a list of covered diagnoses to the provider so they can pick something to rectify an already denied claim. That would be a big no no. She could send a non-leading query to the physician in that case, but not lead them to diagnoses just to get a claim reprocessed and paid.
 
0
sls314 said:
Using a list as an educational tool for future claims is fine.

However, in her original post, it sounds like she's being told to send a list of covered diagnoses to the provider so they can pick something to rectify an already denied claim. That would be a big no no. She could send a non-leading query to the physician in that case, but not lead them to diagnoses just to get a claim reprocessed and paid.
Click to expand...
Yes, my bad there. Still a good thing to know anyway.

The only time I asked after a denial is if they sent me a ton of SDOH codes and I have to go "Umm...anything else you got there that is an actual illness or symptom?"

ETA: We do try to catch these before they go out the door but sometimes our system doesn't go "Whoa there buddy, there is a problem here."
 
0
sls314 said:
Using a list as an educational tool for future claims is fine.

However, in her original post, it sounds like she's being told to send a list of covered diagnoses to the provider so they can pick something to rectify an already denied claim. That would be a big no no. She could send a non-leading query to the physician in that case, but not lead them to diagnoses just to get a claim reprocessed and paid.
Click to expand...
I'm being directed to send the approved dx list to see if a code can be added that hasn't already been billed, but would be supported by the documentation. My question is: can a code be added for example 8 months after the claim was submitted? I just don't know the guidelines for denials since I've never done these before.
 
0
mrsrobinson525 said:
I'm being directed to send the approved dx list to see if a code can be added that hasn't already been billed, but would be supported by the documentation. My question is: can a code be added for example 8 months after the claim was submitted? I just don't know the guidelines for denials since I've never done these before.
Click to expand...

If the diagnosis is already supported by existing documentation, why does it need to go back to the provider at all? A coder can add diagnoses based on documentation.

In the original post, it sounded like you were talking about situations where a diagnosis wasn't supported by the documentation:

If nothing is covered in the patient's chart or problem list, I've been told to send back the CMS-approved diagnosis list to see if the provider can find anything that is appropriate for the patient.

You cannot do that. The provider can't look at a list of covered diagnoses and pick something that will get a denied claim paid.

The physician can be queried in a compliant, non-leading way, and they can make addendums to documentation. In theory, you can update diagnoses and resubmit a claim for as long as the payer's limit for filing corrected claims.

That being said, one might wonder how well the physician remembers the specifics of an encounter 8 months later.

Here's a Medicare Learning Network fact sheet on Complying with Documentation Requirements for Lab Services: https://www.cms.gov/files/document/mln909221-complying-documentation-requirements-lab-services.pdf

Providers are responsible for complying with these documentation requirements when they're ordering diagnostic labs and x-rays for Medicare patients. If there's a pattern of denials, it sounds like the providers could use some training and education. It's okay if they're aware of the payer's medical necessity requirements as a tool when ordering and documenting services going forward.
 
1
I don't know what kind of claims volume we're talking about with your employer. If I were the manager in this scenario, I'd look at the big picture. My staff's time, the provider's time, and maybe even the potential for getting flagged for an audit.

I would have my staff update the claims where there was already clear documentation that supported a diagnosis change. Then, I'd be inclined to adjust the rest and use those claims as an educational tool for the providers.

No one likes to write off denials. (I absolutely hate doing that!) However, there comes a point when you just have to focus on improving things going forward. If the past documentation wasn't adequate, it is what it is.
 
You must log in or register to reply here.
Top