Claims Denials Claiming ICD-10-CM Problems?

Several members have contacted the ICS this week about claim denials from Blue Cross Blue Shield of Illinois (BCBSIL). It appears that BCBSIL has begun to use a claims edit process called “Excludes1” described in ICD-10. This process may result in certain claim denials, as explained in the video. ICS Members can also access the ICD-10 reference sheet here.

Important Note: The video indicates to “resubmit” the bill. Instead, please file a corrected claim. Do not resubmit – file a corrected claim.

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Transcript:

Marc:
I want to thank you for joining us today, we’re doing a quick short tutorial, several of our doctors, many of our doctors, as a matter of fact, are starting to see some claims denials come through from Blue Cross Blue Shield of Illinois, and it seems to all be pertaining to ICD 10 codes. Apparently, BlueCross BlueShield is now using a new claims edit software company to run all of their claims through and that particular company is utilizing something called excludes one. Now many of you probably don’t have a whole lot of information or know a whole lot about the excludes one, and what that actually means, and how to overcome it. So what I’ve done is I’ve asked Dr. Evan Gwilliam, to join us today. He is the clinical director with PayDC and actually joined us just this last weekend at the Heartland Symposium in Springfield, Illinois, and educated our doctors there. But he’s a good friend of mine. You can see he’s got a ton of letters after his name. But really what that means is he’s incredibly educated, he knows his stuff. And he was one of the first people that I contacted to help get the information out to our doctors. Dr. Gwilliam? Tell us what’s going on here.

Dr. Gwilliam:
Alright, Marc, so ICD 10 kicked in, in 2015. And when it kicked in, we all freaked out, we weren’t sure it was gonna happen is like y2k, right? It was this big change. One of the things we had to learn was these new conventions and rules. This rule about excludes one and excludes two are things that they outlined very clearly in their guidelines. They’re a little weird, though, the way they chose the wording and stuff. So I’m going to take a minute and explain to our listeners, just what these rules are. And I want to make sure that everybody knows how to apply the codes properly.

ICD 10 is funny because they don’t necessarily tell us how to practice or what how to make our clinical decisions. But there are rules about which codes can go together. And the excludes is basically about which codes can go together and which ones can’t. So if I pulled out my book here, you know, I got my code book. And I look up a code in here, and I come across it. And underneath the code, it says excludes one, I need to read that to mean not coded here. So underneath it, I would see another list of codes or a code or two or three. And that means that you cannot code both of these are mutually exclusive to each other. Here’s a great example, acquired deformity of the spine and congenital deformity of a spine. Those are excellent when they’re mutually exclusive. Either it’s acquired or it’s congenital, you can’t have both. And that’s an example of where it excludes one would clearly say use this code and not that one.

Excludes two is different. This is for not included here. And you are probably not going to see denials around this one as much. What it means here so I look at my code, and then it says excludes two, and it lists some other codes, it says consider these codes because they’re not included in the one that you’ve chosen, you need to report them separately in order to get credit for having both of them there. So I wish they had used the word excludes two, I wish they just called it not included. I think that would make more sense. So you have to think that if you come across this excludes two. I don’t think so, one’s gonna give you denials per se, like the excludes one, because the excludes one, they’re saying you’ve used two codes, and they’re not allowed to be used together. That’s basically what you’re doing.

So let me just kind of reiterate this excludes one, when you see it, I want you to think consider these codes instead. So if there’s a code with an excellent one, you can only use one of them, you can use that code or the other one, one of the others in the list. They’re mutually exclusive to each other. If you see excludes two, it means consider these codes in addition, because they’re not already included in that one, you can use two or more. So the two kind of tips off and they’re not included. Alright, so that’s the gist of excellence, one excellence two, I’ve, I knew this was going to be an issue back when we taught it back in 2015, and 14, and we’re getting ready for this. And I was waiting for the payers to begin to use it as another way for them to deny care.

So here’s an example just to kind of illustrate this. If you look at this code that was new to us last year, N5450, low back pain unspecified. You look it up in the codebook. It says excellent one, and it lists three codes. This means that you cannot list these other codes with low back pain. Basically, they’re saying they’re suggesting that if you have a low back strain, or lumbago, due to a disc or lumbago, with sciatica, that means they already have low back pain and you don’t have to code. You can’t code the low back pain. In addition, it’s redundant, and it would flag it and apparently, this reviewer’s software where they have this built-in and they’ll just know if they see those codes together, they’re gonna throw out your claim because you don’t need to say low back pain along with these other codes because it’s already included in them. Okay, this is an excludes one.

Just to make sure you understand excludes two, if we look at the code for cervical disk with radiculopathy, you can also code for brachial radiculitis on the same claim if you want excludes two means consider these codes in addition, so someone could have a disorder with radiculopathy and brachial radiculitis, those are two separate conditions. And they’re trying to say with excludes two that they’re not included in each other. If you want to report them, you got to report both whereas excludes one you can’t report both. Alright, so that’s the gist of the rules here with excludes. Basically you need to know if you’re using codes that aren’t allowed to be used. together. And if you are the payers now have another reason to throw out your claims. And so you just got to figure out what these rules are. And there’s gonna be some common ones in chiropractic. Marc and I are gonna run through a few of them with you here. So let me move my slides.

Marc:
Yeah, let me ask a couple of quick, just quick questions and make sure that we’re all on the same page here. So we’re seeing denials, and maybe we have four different diagnosis codes on a claim form. It could be that the two of those have, what they call excludes one notes, if you will, on those particular ICD 10 codes. And that just basically means they should not be billing them on the same claim form.

Dr. Gwilliam:
That’s right. That’s exactly right. They’re suggesting that we unlikely or impossible for a patient to have both of those conditions because they either overlap or whatever reason. I’m gonna say that for some of them, don’t question it. Some of them do not make sense. But that’s okay. Just understand, that’s the rule, and just don’t use them together and figure out a better way to document everything you can in your records to show what’s really true. And then figure out the coding rules after the fact and apply the codes as best you can, you know, they’re not perfect. They mostly make sense, though.

Marc:
So, on some of these cases, if they can figure out exactly which ones have the excludes one, and I do want to tell you this really quick ICS members, you are going to be getting a resource. It’s a it’s a document that gives you the vast majority of these excludes one codes to be able to identify and figure out exactly what the problem is. And so you can figure out what do you need to take off your claim form. In these cases, simply take off what it what it requires. And if you can replace it with something better, that is not in that excludes one list, then great. Otherwise, take it off, and resubmit that bill for payment. That’s what Blue Cross has indicated in these denials is that you can fix that ICD 10 code and resubmit it for payments. So Doctor, Gwilliam you want to take a look at some of these, I think you’ve actually got one queued up already. We this is an actual one that we got sent into us N54.42, N51.17, N99.04, and M47.814. This is an actual claim form that was denied by Blue Cross Blue Shield received the remittance advice this week.

Dr. Gwilliam:
Okay, so let me show you guys why it was denied. This is a tool that I use called Find A Code, it’s a subscription service for online coding, you can get it instead of books basically. So you might wanna check it out. It’s a great tool, I use it all the time in my work. One of the tools they have built-in here is this ICD 10 validator. So I copied in the four codes that Marc just mentioned, I hit validate, and it shows me either an error or warning. Errors or conflict, the codes cannot be built together. Warning, say there’s something going on, you should look into it more closely. So we see forN4542, which is lumbago sciatica on the left. There’s an error, it says you can’t have a patient with lumbago sciatica, along with an intervertebral disc disorder, they won’t allow those codes to be built together and occludes. One, they’re mutually exclusive to each other. So you can’t put those on the same claim form. That’s why this claim, this code combination was denied. Then it took the M 5117, which was the disk with radiculopathy. And said, Yep, you can’t have a disk with radiculopathy along with lumbago sciatica. They just have it excludes one. So it’s an error, and you can’t do it. And so the question is, what about these other codes? Well, this validator tells us that the segmental dysfunction code had nothing to do with it. There’s no excludes with that one that affects the code combinations we have. Same thing with the spondylosis code they used, it’s okay to use that one together with the other codes. Basically, what we need to do in this case is either get rid of the M 5117 or get rid of the M 5442. And the claim should go through just fine. That’s the story.

Marc:
Yeah, you’ve got it cued up. So we’re talking about M 51.14, M 54.16 and I believe, is that it? M 54.2

Dr. Gwilliam:
M 5114 is intervertebral disc disorders with radiculopathy. It has an exclusion for M 5416, which is lumbar radiculitis. They’re saying if you have a disc with radiculopathy, you can also say radiculitis. You can’t code for both of those. It’s either they have a disc with 3radiculopathy or just radiculitis. And then they have another one for the M 511. So for the disk with radiculitis if we scroll down the M 5442 is okay, as a warning, we should check it out. This doesn’t affect the denial. In this case, the warning is okay. And then for the M 5416. It shows us again that the M 511. And the M 5416. cannot be billed together. And so also can’t be billed with the M. Well, it’s saying it’s the same kind of thing with a different order. So the list that Marc’s gonna send you probably has all the stuff summarized on a piece of paper, you’re good to go. Honestly, if you guys are really stumped, shoot me an email and I’ll drop them in here for you email you back, and tell you what it does, you know, print the screen and send it to you. It’s no big deal. Or you can go subscribe to find a code if you really want but I’ll run through my validator for you. And we’ll figure it out. That’s the story though. certain codes can’t be done together. And if they can’t, the payer is going to deny it.

Marc:
So Dr. Gwilliam, we really appreciate you offering that what is your email address? Do you mind hopping back over and pulling it up so everyone can see?

Dr. Gwilliam:
Sure I’ll just drop it up there again. So there’s my email address. It’s my name @paydc.com, Evan.gwilliam@paydc. And just a fair warning, at the end of the email, I’ll say, Hey, you want to look at my software? So just be prepared for that. And you can just say no, and it’s fine. But if you say yes, I’ll show it to you. And you guys can see really great thing I’ve got All right.

Marc:
Great, Doctor Gwilliam, thank you so much for joining us today and hopping on and explaining to our members in here in Illinois exactly what’s going on. This is fantastic. And hopefully, it’s gonna be a great resource for our doctors to be able to understand what’s going on with their denials. Why all of the sudden this is happening and really this all comes down to they announced at the end of last year that they’re going to do no quarterly updates here in in April. And I think now what we’re seeing is not only are we getting the new updates, but the consequences of them having a new claims edit provider for them, who is utilizing the excludes one. Thank you Doctor Gwilliam for joining us. And for the rest of you. We’ll catch you next week.

Dr. Gwilliam:
Thanks, Marc.