Responses for post: Sequela Codes & Unspecified ICD-10 Billing Issues
Melissa Edwards
Description
Collection
Title:
Responses for post: Sequela Codes & Unspecified ICD-10 Billing Issues
Creator:
Melissa Edwards
Date:
6/5/2019
Text:
The response I received from Medicare was verbally as they called me instead of responding to my email.
I was told that unless the LCD specifically states it is diagnosis driven that it should not matter. When I gave the representative a specific example with codes (not dx driven) with dx she stated we should process the claim and watch it. If there was an issue when billed to forward the CCN to her for further review. Our biller is very apprehensive given the numerous issues we have already seen. We would always prefer to get it right the first time than to go through a denied claim. The example I gave her was:
Bilateral Double Upright AFO's attached to Orthopedic Shoes
[cid: <Email Address Redacted> ]
The physician gaveICD-10
E11.9- Primary
M86.171- Secondary
S82.899S- Tertiary
S92.011S- Quaternary
M25.572- Quinary
List Serv Respsonses:
We have had no problems with Medicare or any carrier billing sequela codes. Medicare does require coding to the highest level of specificity and do not accept unspecified when a more detailed code exists. Have the denials actually said sequela was not acceptable? All of those codes you have referenced state unspecified. Also, this industry never bills with an A as a matter of fact we are always the sequela as per all the webinars I have taken.
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Our clinic is experiencing the same issues with the first three codes. We have not found anything that get us paid on these codes, but if people respond we would love to know what advice you get.
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We have had some of the same issues going on. From everything I have researched, we are to use Initial instead of Sequela on the dx codes. Insurances won't accept Sequela for our types of supplies with DME O&P.
I have not had any deny yet for not being able to have the S at the beginning. Those are all valid codes for fractures to my knowledge. Very strange for them to say that!
Claims WILL deny if there is unspecified anywhere on a dx code that has to do with a body part. They have to be as specific as possible.
Have you read the icd 10 specifics in the Medicare LCDs? I cannot speak of other Medicare regions but Noridian lists do codes acceptable for various L codes. Not all but many. I often have to go back to the doc and ask them to add a code to their lists of diagnoses.
If you use a sequela dx you need to list the underlying dx that caused that issue as the primary dx first.
I have not had any issues with Aetna BH on S codes as of yet. Any time that I have a dx code that states unspecified to a body part I change the code on my side to specify the correct side. You are not falsifying a record by doing that. If the information that defines the side or section is within the body of the clinical notes but they have coded it as unspecified there is no reason you cannot code your side with the specified side.
Melissa Edwards
Business Operations Manager
[New Logo- VP&O B&W]
4338 Williamson Rd. NW
Roanoke, VA 24012
P:(540) 366-8287
F: (540) 767-0010
<Email Address Redacted>
THE DOCUMENTS ACCOMPANYING THIS TRANSMISSION CONTAIN CONFIDENTIAL HEALTH INFORMATION THAT IS LEGALLY PRIVILEGED. THIS INFORMATION IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR ENTITY NAMED ABOVE. THE AUTHORIZED RECEIPIENT OF THIS INFORMATION IS PROHIBITED FROM DISCLOSING THIS INFORMATION TO ANY OTHER PARTY UNLESS REQUIRED TO DO SO BY LAW OR REGULATION AND IS REQUIRED TO DESTROY THE INFORMATION AFTER ITS STATED NEED HAS BEEN FULFILLED.
IF YOU ARE NOT THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISCLOSURE, COPYING DISTRIBUTION, OR ACTION TAKEN IN RELIANCE ON THE CONTENTS OF THESE DOCUMENTS IS STRICTLY PROHIBITED. IF YOU RECEIVED THIS INFORMATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY AND ARRANGE FOR THE RETURN OR DESTRUCTION OF THESE DOCUMENTS.
I was told that unless the LCD specifically states it is diagnosis driven that it should not matter. When I gave the representative a specific example with codes (not dx driven) with dx she stated we should process the claim and watch it. If there was an issue when billed to forward the CCN to her for further review. Our biller is very apprehensive given the numerous issues we have already seen. We would always prefer to get it right the first time than to go through a denied claim. The example I gave her was:
Bilateral Double Upright AFO's attached to Orthopedic Shoes
[cid: <Email Address Redacted> ]
The physician gaveICD-10
E11.9- Primary
M86.171- Secondary
S82.899S- Tertiary
S92.011S- Quaternary
M25.572- Quinary
List Serv Respsonses:
We have had no problems with Medicare or any carrier billing sequela codes. Medicare does require coding to the highest level of specificity and do not accept unspecified when a more detailed code exists. Have the denials actually said sequela was not acceptable? All of those codes you have referenced state unspecified. Also, this industry never bills with an A as a matter of fact we are always the sequela as per all the webinars I have taken.
------------------------------------------------------------------------------------------------
Our clinic is experiencing the same issues with the first three codes. We have not found anything that get us paid on these codes, but if people respond we would love to know what advice you get.
----------------------------------------------------------------------------------------------------
We have had some of the same issues going on. From everything I have researched, we are to use Initial instead of Sequela on the dx codes. Insurances won't accept Sequela for our types of supplies with DME O&P.
I have not had any deny yet for not being able to have the S at the beginning. Those are all valid codes for fractures to my knowledge. Very strange for them to say that!
Claims WILL deny if there is unspecified anywhere on a dx code that has to do with a body part. They have to be as specific as possible.
Have you read the icd 10 specifics in the Medicare LCDs? I cannot speak of other Medicare regions but Noridian lists do codes acceptable for various L codes. Not all but many. I often have to go back to the doc and ask them to add a code to their lists of diagnoses.
If you use a sequela dx you need to list the underlying dx that caused that issue as the primary dx first.
I have not had any issues with Aetna BH on S codes as of yet. Any time that I have a dx code that states unspecified to a body part I change the code on my side to specify the correct side. You are not falsifying a record by doing that. If the information that defines the side or section is within the body of the clinical notes but they have coded it as unspecified there is no reason you cannot code your side with the specified side.
Melissa Edwards
Business Operations Manager
[New Logo- VP&O B&W]
4338 Williamson Rd. NW
Roanoke, VA 24012
P:(540) 366-8287
F: (540) 767-0010
<Email Address Redacted>
THE DOCUMENTS ACCOMPANYING THIS TRANSMISSION CONTAIN CONFIDENTIAL HEALTH INFORMATION THAT IS LEGALLY PRIVILEGED. THIS INFORMATION IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR ENTITY NAMED ABOVE. THE AUTHORIZED RECEIPIENT OF THIS INFORMATION IS PROHIBITED FROM DISCLOSING THIS INFORMATION TO ANY OTHER PARTY UNLESS REQUIRED TO DO SO BY LAW OR REGULATION AND IS REQUIRED TO DESTROY THE INFORMATION AFTER ITS STATED NEED HAS BEEN FULFILLED.
IF YOU ARE NOT THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISCLOSURE, COPYING DISTRIBUTION, OR ACTION TAKEN IN RELIANCE ON THE CONTENTS OF THESE DOCUMENTS IS STRICTLY PROHIBITED. IF YOU RECEIVED THIS INFORMATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY AND ARRANGE FOR THE RETURN OR DESTRUCTION OF THESE DOCUMENTS.
Citation
Melissa Edwards, “Responses for post: Sequela Codes & Unspecified ICD-10 Billing Issues,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/209510.
