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Thursday, July 1, 2010

Insurance denial - IMPROPER DIAGNOSIS or INCORRECT DIAGNOSIS

IMPROPER DIAGNOSIS or INCORRECT DIAGNOSIS

Description:
Services were denied because the diagnosis listed as primary was not a covered diagnosis for the procedures performed.

ACTION:

Check your specific carrier's local coverage determination (LCD) policy for the specified procedure to obtain a list of covered diagnoses, generally found on their Web site, or accessible on Medicare's Web site. Also familiarize yourself with the appropriate policies for medical necessity and documentation requirements. Be cautious of automated programs/software that provide a covered diagnosis for any given procedure. Keep in mind that having a covered diagnosis does not mean you can automatically perform any procedure for which the covered diagnosis exists. You must prove and document the reason in the medical record to justify doing the procedure. For example, let's look at doing routine anterior segment photography because your patient presents with allergic conjunctivitis. Despite having a "covered diagnosis" for taking the photo, there most likely is insufficient medical necessity to take an annual photo of the allergic eye.

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