www.njchiropractors.com I 13 Diagnosis Coding Alert: We have seen a great number of denials based on diagnosis codes since the turn of the year. These have occurred mostly with Horizon and Amerihealth claims. There are three known reasons for diagnosis-code- based denials. The first, and most common, issue has been that the doctor reported two or more ICD-10 codes that are considered mutually exclusive to each other. There are two categories that can be attached to ICD-10 codes called Excludes1 and Excludes2. If there are codes in these categories, they will be listed below the ICD-10 code in either your ICD-10 codebook or online resource. If a code is listed as Excludes1, it means these two codes cannot be reported on the same claim. Excludes2 codes are essentially codes that are related to your chosen code that you may want to report as well, if appropriate. If you have received denials based on your diagnosis codes, check to see if any of the codes you reported are Excludes1 to any of your other reported diagnosis codes. The Excludes1 listings would appear this way: M54.5 Low back pain Including: Loin pain, Lumbago NOS Excludes1: low back strain (S39.012)  lumbago due to intervertebral disc displacement (M51.2) lumbago with sciatica (54.4-) In this example, if you had entered diagnosis code M54.5 on your claim, you would NOT be allowed to also enter these three diagnosis codes - S39.012, M51.2 or any code beginning with M54.4. If you did, they could be rejected by the carrier. Another potential reason for diagnosis-code-based denial is using an unspecified code. Unspecified codes are often part of a series of ICD-10 codes broken down by laterality or vertebral segments. For example, M50.120 represents “cervical disc disorder with radiculopathy, mid-cervical region – unspecified.” This could be denied by a carrier as an unspecified code. You should always use the most specific ICD-10 code available. In this example there are codes for specific vertebral levels such as M50.121, “Cervical disc disorder with radiculopathy – C4-C5 level.” This rule of specificity applies to laterality as well. For instance, you should not use M54.30, “sciatica, unspecified side.” Instead you should report either M54.31, “sciatica, right side,” M54.32 “sciatica, left side” or both, if applicable. The last, and least common, diagnosis code denial issue is not having enough diagnosis codes to justify the treatment rendered. For example, if you were to bill for a 98942 five region adjustment, but did not have a diagnosis code for each of the five regions that were presumably adjusted, carriers may deny this claim. This could also serve as a trigger for an audit or more investigation by some carriers. For more information and detail on this topic please see the recording of Dave Klein’s webinar “ICD-10 Coding Review – Stop the Denials.” You can find this webinar at our website, www.anjc.info, under the Education tab > Webinars > 2019 Webinars > “ICD-10 Coding Review – Stop the Denials.” United-Optum: Beginning July 1, 2019, United Healthcare will require the GP modifier to be appended to any codes that are deemed “Always Therapy” codes according to CMS. These codes will include: 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762*, 97799, G0281, G0283. This policy change was announced in the United Network Bulletin April 2019 (page 25) and United advises that a letter was sent to providers in April. You can view both the newsletter and the United letter to providers at our website www.anjc.info if you go to the Insurance tab > News and Updates > United to Require GP Modifier as of July 1, 2019 (posted May 29, 2019). You may have received a denial for not having this modifier in the last few weeks of May. United has advised the ANJC that due to a coding error the claim edit went into effect early. The issue has been resolved and corrected payments should be in process. If you have an outstanding denial for this reason, please email me at matt@anjc.info. Note: it is NOT advised that you add this GP modifier to other carriers who have not explicitly required it as part of their policy. Share your success. Eight out of 10 alumni agree that having a Palmer degree gives them an edge on their competitors. Refer a student to Palmer College. www.palmer.edu/recruit-a-student The Trusted Leader in Chiropractic Education®