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    Unlisted diagnosis codes could lead to denials

    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. 


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