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Improper Diagnosis Codes Causing Claim Denials
Who determines the patient’s diagnosis codes when a patient enters your facility under managed care? Which codes are being used to obtain the authorization and are they really appropriate? If it is admissions, are they trained for this? Are they collaborating with nursing or MDS for appropriate codes?
Health plans are cracking down on inappropriate diagnosis codes and denying claims as such. All too often, we see claims denying because the codes utilized are not correct.
Example: S72.92XA “Unspecified fracture of left femur, initial encounter for closed fracture” would be used by the hospital and would likely be the diagnosis on the referral. However, a SNF does not do initial encounters; SNFs provide after care. Z47.89 “Encounter for other orthopedic aftercare” would be one of the choices as a more appropriate code for a SNF. It is important to validate what codes your team is using, not only the admission diagnosis, but also for submission of the claim. This is another reason why Triple Check for managed care is just as important as it is for Medicare.
Some things to think about - does your team do Triple Checks? Was there pushback from the team to include managed care?
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