Medicare keeps denying labs

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Indodo

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Hi,

I have been taking medicare patients for a while.
lately after a local community center went bankrupt, i decided to take a few patients.

One current issue I keep having is that medicare keeps denying coverage for labs like cbc, chem panel, lipids, hemoglobin A1c.
The labs (quest/labcorp) don't know what it is either other than we have the wrong codes.

I am using the standard codes for bipolar/schizophrenia. F31.x, F20.x etc.

Anyone else having this issues/have experience with this?
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Indodo said:
Hi,

I have been taking medicare patients for a while.
lately after a local community center went bankrupt, i decided to take a few patients.

One current issue I keep having is that medicare keeps denying coverage for labs like cbc, chem panel, lipids, hemoglobin A1c.
The labs (quest/labcorp) don't know what it is either other than we have the wrong codes.

I am using the standard codes for bipolar/schizophrenia. F31.x, F20.x etc.

Anyone else having this issues/have experience with this?
Click to expand...
Medicare is very fussy about this sort of thing.

I'm not a psychiatrist but I'm assuming you're checking those labs because of the medications those conditions treat, right (anti-psychotics and that whole metabolic syndrome thing)?

If so,maybe try Z79.889

Also, medicare generally won't cover an A1c unless you use codes proving hyperglycemia that you found elsewhere (say on the chem panel) or things like diabetes.
 
VA Hopeful Dr said:
Medicare is very fussy about this sort of thing.

I'm not a psychiatrist but I'm assuming you're checking those labs because of the medications those conditions treat, right (anti-psychotics and that whole metabolic syndrome thing)?

If so,maybe try Z79.889

Also, medicare generally won't cover an A1c unless you use codes proving hyperglycemia that you found elsewhere (say on the chem panel) or things like diabetes.
Click to expand...

Our SMI service line had the same problem until they started coding z79.889 as above, et voila, no trouble getting metabolic labs and lithium levels covered. We don't use paper scripts much anymore but when that was still a thing the prescription pads for that service had the code as a box to check along with the mental health diagnosis. They also insist on marking the Z code as primary for lab orders but I am not sure if that really has an effect.

We've not had trouble with getting A1Cs for people on chronic neuroleptics, there are enough guidelines saying this is necessary that it seems to prevail round here.
 
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I’ve always used that Zcode mentioned above for any labs related to medication management and never heard of any issues.
 
Thanks everyone,

Never used the zcode before. Will start now. Had a patient get charged 450 for labs. Going to try and get that reversed.

I was just trying to help out. Most medicare patients were seen (still are) through the community clinics. I never have this issue with older medicare pts. That may be because almost none of them are on antipsychotics or they already have labs via their pcp. However I must have ordered it before without a problem in that community somewhere. Maybe the managed medicare like united/anthem doesn't follow this rule?

Oh well. A good deed never goes unpunished.
 
A frustration with several labs is they want a diagnosis code when the patient is not known to have the diagnosis. E.g. if I order a lab to rule out a vitamin D deficiency I don't know if the patient has it, but they want me to write down a diagnosis when technically that means the patient has that problem.

I never did it to a forensic fellow but I was thinking of putting them on the spot during a mock trial.

Me: So Dr. X you ordered a Vitamin D lab. Why?
Him: Because I wanted to see if he had a Vitamin D deficiency.
Me: So you put down a diagnosis of Vitamin D Deficiency but you really didn't know he had it. Is that correct?
Him: Yes.
Me: So do you usually write down a diagnosis down when you're really don't know if that patient has it?
Him: Umm. (Pauses, looks at others as if struggling for an answer).
Me: So what else is on your report that you wrote down as conclusion when in fact you really don't know?
Him: Umm, well you see they want us to write a diagnosis for billing purposes.
Me: Ah, so you write down something for monetary purpose as if the patient has that problem when in fact you really don't know? Is that what you're saying?
 
whopper said:
A frustration with several labs is they want a diagnosis code when the patient is not known to have the diagnosis. E.g. if I order a lab to rule out a vitamin D deficiency I don't know if the patient has it, but they want me to write down a diagnosis when technically that means the patient has that problem.

I never did it to a forensic fellow but I was thinking of putting them on the spot during a mock trial.

Me: So Dr. X you ordered a Vitamin D lab. Why?
Him: Because I wanted to see if he had a Vitamin D deficiency.
Me: So you put down a diagnosis of Vitamin D Deficiency but you really didn't know he had it. Is that correct?
Him: Yes.
Me: So do you usually write down a diagnosis down when you're really don't know if that patient has it?
Him: Umm. (Pauses, looks at others as if struggling for an answer).
Me: So what else is on your report that you wrote down as conclusion when in fact you really don't know?
Him: Umm, well you see they want us to write a diagnosis for billing purposes.
Me: Ah, so you write down something for monetary purpose as if the patient has that problem when in fact you really don't know? Is that what you're saying?
Click to expand...

Our billers tell us we have to diagnose sleep apnea before we order a home sleep study. I can't even.
 
From my med school days I was taught in the Primary Care arena it is common to put the diagnosis you are chasing after or concerned about.
For instance, you think there is a fracture, and want to find out on imaging, you put down non-specific fx dx.
Charting is where you put your thoughts of rule out fx or concerns for fx, etc.

But yeah, I hear y'all on some of the more concerning diagnoses you don't exactly when that perpetuated into EMR land. But as long as insurance companies deny for various reasons we'll still need to put down Dx that gets it covered, as that matters more the clinical care and "medical necessity."
 
Sushirolls said:
From my med school days I was taught in the Primary Care arena it is common to put the diagnosis you are chasing after or concerned about.
For instance, you think there is a fracture, and want to find out on imaging, you put down non-specific fx dx.
Charting is where you put your thoughts of rule out fx or concerns for fx, etc.

But yeah, I hear y'all on some of the more concerning diagnoses you don't exactly when that perpetuated into EMR land. But as long as insurance companies deny for various reasons we'll still need to put down Dx that gets it covered, as that matters more the clinical care and "medical necessity."
Click to expand...
That's a bad way to practice, generally speaking. There are codes for symptoms that you should use if you're not sure. For sleep stuff I use fatigue, snoring and obesity. Haven't had one denied in years.
 
VA Hopeful Dr said:
That's a bad way to practice, generally speaking. There are codes for symptoms that you should use if you're not sure. For sleep stuff I use fatigue, snoring and obesity. Haven't had one denied in years.
Click to expand...
Agree its bad. I opt for generic non-specific things until actual diagnoses can be gleaned as is customary in Psychiatry. But as others have pointed out, some insurance companies get cantankerous and want more precise diagnosis for the very test meant to ascertain the diagnosis in question.

I've run into issues with urine HCG tests. Putting down the presenting mental health diagnosis isn't good enough for some insurance companies, I've then had to put down the pregancy Z code. Positively, I have the test result in hand before I finish my documentation and submission to billers, but that's not always the case.

For instance I had to do an imaging prior auth for a first break psychosis patient. Unspecified psychosis wasn't specific enough for the nurse reviewer and ultimately she/I discovered that 'altered mental status' got it through their computer system. Psych wasn't even on their radar for outpatient prior auths of brain imaging.
 
whopper said:
A frustration with several labs is they want a diagnosis code when the patient is not known to have the diagnosis. E.g. if I order a lab to rule out a vitamin D deficiency I don't know if the patient has it, but they want me to write down a diagnosis when technically that means the patient has that problem.

I never did it to a forensic fellow but I was thinking of putting them on the spot during a mock trial.

Me: So Dr. X you ordered a Vitamin D lab. Why?
Him: Because I wanted to see if he had a Vitamin D deficiency.
Me: So you put down a diagnosis of Vitamin D Deficiency but you really didn't know he had it. Is that correct?
Him: Yes.
Me: So do you usually write down a diagnosis down when you're really don't know if that patient has it?
Him: Umm. (Pauses, looks at others as if struggling for an answer).
Me: So what else is on your report that you wrote down as conclusion when in fact you really don't know?
Him: Umm, well you see they want us to write a diagnosis for billing purposes.
Me: Ah, so you write down something for monetary purpose as if the patient has that problem when in fact you really don't know? Is that what you're saying?
Click to expand...
The legal system in America is the only source of truth
 
clausewitz2 said:
Our billers tell us we have to diagnose sleep apnea before we order a home sleep study. I can't even.
Click to expand...
My insurance company keeps sending me mailers with things I should do based on my medical history (get an eye exam, flu shot, etc.). One that they keep saying I should do is a sleep study. Long before this, I had a pulmonologist try to schedule me for a sleep study and could not get this same insurance company to approve it. They even did a peer to peer. I wonder if I can use these mailers as benefit approval.
 
birchswing said:
My insurance company keeps sending me mailers with things I should do based on my medical history (get an eye exam, flu shot, etc.). One that they keep saying I should do is a sleep study. Long before this, I had a pulmonologist try to schedule me for a sleep study and could not get this same insurance company to approve it. They even did a peer to peer. I wonder if I can use these mailers as benefit approval.
Click to expand...

The right hand does not know what the left hand is doing unfortunately.
 
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