Wiki Non-Asterisk systemic diagnosis Denials

[kle0204]

Hello,

I understand that in the CMS A52996 Routine Foot Care reference, the systemic ICDs with the asterisk (*) indicates that a managing provider and an approximate date last seen for the condition is required. I initially thought that the ones WITHOUT the asterisk, for example, I73.9 Peripheral vascular disease, unspecified, doesn't require those information; however, I'm starting to get denials and when my AR department called Novitas to get more information, they were told that a REFERRING provider is required, (it doesn't have to be a Managing provider), and that the Date last seen WAS NOT needed. My AR dept called again on a different day with the same denial and was told by a different person that the Referring provider is required AS WELL AS the Date Last Seen.

There are also encounters where the patient is a self referral, so there won't be a referring provider for me to add to the claim.

Can someone please advise me on how to proceed with these scenarios? I make sure to have a medical necessary ICD from Group 1 and a Q modifier on my RFC procedures. It's the referring provider vs managing provider vs date last seen that I'm unsure with. It seems like every time I think I got podiatry coding down, something else pops up and I feel like I'm back to square one, so I would really appreciate any help!

Thank you!

 

[podcoder70]

Novitas is a funny one...for RFC, they, like all the others want the primary treating provider and approximate date last seen for the diagnosis codes with the asterisk. However, they ALSO want a "referring provider" name entered on all of the claims with non-asterisked diagnosis codes as well (not the DLS). It is my understanding that this can be the name of the podiatrist if the patient is not being seen on a regular basis by a primary care doctor. Most have a doctor of record and that name would be the best one to use.

 

[kle0204]

Novitas is a funny one...for RFC, they, like all the others want the primary treating provider and approximate date last seen for the diagnosis codes with the asterisk. However, they ALSO want a "referring provider" name entered on all of the claims with non-asterisked diagnosis codes as well (not the DLS). It is my understanding that this can be the name of the podiatrist if the patient is not being seen on a regular basis by a primary care doctor. Most have a doctor of record and that name would be the best one to use.

Thank you for confirming this! And I'm sorry for adding on to this, but I know Medicare requires the Q modifiers and currently, I just add it on all insurances because the majority follows Medicare guidelines. Do you happen to know if there are commercial insurances that does not require the Q modifiers as long as you have a medically necessary diagnosis? Or is adding the Q modifier across the board the safest bet?

Thank you!

 

[podcoder70]

Thank you for confirming this! And I'm sorry for adding on to this, but I know Medicare requires the Q modifiers and currently, I just add it on all insurances because the majority follows Medicare guidelines. Do you happen to know if there are commercial insurances that does not require the Q modifiers as long as you have a medically necessary diagnosis? Or is adding the Q modifier across the board the safest bet?

Thank you!

Each jurisdiction has different requirements. For example, Novitas requires documented class findings and the q modifier for routine foot care coverage. However, other jurisdictions only require the q mod for vascular systemic conditions. The medicare advantage plans follow the same rule. The commercial plans do not require it and I do not use it on commercial plans.