Hearing Rumors About BCBSIL Requiring M99 Codes?

Blue Cross Blue Shield of Illinois is denying chiropractic claims over ICD 10 issues. Learn why missing M99 codes and poor diagnosis pointing can trigger denials and how to tell the right story on your claim.

Transcript:

Marc:
We received a question this week from one of our members, indicating that she had a friend who was seeing some Blue Cross, Blue Shield of Illinois, denials directly related to ICD 10. More specifically, it was really directly related to not including enough segmental dysfunction codes. Brandy is our COO with Practisync over the billing operations. So she is our expert in all things related to billing. Brandy. What are you seeing as far as Blue Cross, Blue Shield of Illinois, and this whole issue with ICD 10?

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Brandy:
Perfect. So while there are many things that can happen that cause a claim or a line item to not process the way we expect it would, I think, or the way we expect it should. I should say, I think that going back to the sort of the fundamentals, your service codes say this is what I’m doing with your patient. Your diagnosis codes say this is why I’m doing that with the patient. So in order to have a properly coded and complete claim, we have to completely define why we’re doing what we’re doing, in other words, properly diagnose for the services that we’re rendering, which means we should also be pointing our diagnosis to our procedure codes as well.

So, on your more specific question as it relates to the segmental dysfunction codes, yes, if you’re submitting the 98940, 41, or 42, the standard expectation is that we have an appropriate M99 code. If you’re billing for the 98941, you should have three or four spinal-related codes, typically the M99.0, whatever that region is that is supported by your documentation in the claim, and then, of course, pointed to appropriately on the claim form. With that being said, while you might be thinking, well, we’re not using those all the time, and we’re not having any problems, I’m not suggesting across the board that’s carved in stone, and every claim you’re going to submit is going to require those M99 codes. Make good decisions with your coding, know your payers, but understand, if you’re not using those M99 diagnoses, particularly with Blue Cross of Illinois, because they are becoming very particular about it, that could be the reason you’re seeing line item denials for your spinal manipulation. So those are difficult to appeal. Takes a lot of time, so implement the sufficient diagnosis, the M99 diagnosis, and point them appropriately to your spinal adjustments.

Marc:
Yeah, I think you touched on two things, and this is where it gets really interesting. And you’ve heard me talk about this in previous videos. We’ve written about it, Dr Evan Gwilliam and I have been on these types of conversations, and he and I have talked about it. Your Claim Form, you’re telling them the story. They don’t have your documentation. They’re not seeing the patient. They don’t have that firsthand knowledge that you have. So the story that they have in front of them is on the claim form. And so if you don’t have enough diagnosis codes to properly back up the number of regions that you’re adjusting, right? So again, as she mentioned, 998941, having three to four, if you don’t have three or four spinal complaints on the claim form, then you’re not telling the right story to begin with.

I don’t really love the whole requirement of the M99 codes and the segmental dysfunction on every single claim form. I think that’s a misnomer. But it doesn’t really matter what I think at the end of the day; what matters is what Blue Cross, Blue Shield, is expecting to see, and what they’re requiring. And the problem is, we don’t always know. Is this a union issue? Is it a city plan? Is it a large corporate plan? Are they the ones that are crafting some of that policy, where Blue Cross is just acting as a third-party administrator, or is this Blue Cross slowly administering this, this requirement for the segmental dysfunction of the M99 codes for every single one? But, at the beginning, it really doesn’t matter. What matters most is you’re telling the right story. So you have to have all of the diagnosis codes, and Brandy, you touched on this too, diagnosis pointing, which I believe is one of the hardest things to get through to our doctors about how important diagnosis pointing is. Are you seeing stuff with the diagnosis pointing that will kind of align with this, with this change, or this? I call it a new requirement, even though it’s been around for about 18 months with Blue Cross, as it kind of slowly migrates. But anyway, what are you seeing as far as the pointing goes?

Brandy:
The pointing for diagnosis is something that we have long talked about for a good many years that wasn’t so much of interest to payers in years past; that is definitely becoming more of interest to them now. So you might imagine, if you’re reading a book, and as you’re reading each sentence in the book, it puts together the pieces of the story. Well, imagine now that you’re reading a line item on a claim form, and you’re saying this procedure, whatever the code is, and these diagnoses that are supporting it, if it doesn’t match up for the procedures, or if it’s not in alignment with the diagnosing and coding guidelines, you’re telling the payer a confusing story. It makes it very easy for them to deny a claim, to deny a line item, to request more information from the patient, to request more information from the provider, and ultimately delay or even prevent the processing of your claim. So some of it is tell a clean story, point your diagnosis to the appropriate procedure. So just like I mentioned, Procedure Code, say what you’re doing. Diagnosis codes say, why? Just make sure that you’re clarifying that on your claim form, because that’s, that’s the story for that day, or for that service for your patient.

Marc:
Yeah, and that also means, like, if you’re doing, if you’re doing extremity adjusting, and we see this a lot. Brandy, I think you see it as well. And when you’re handling and helping doctors, is a doctor will have an extremity adjustment code, so they’re going to build a 98943, and then they’ll still do their A through D and A through D when they point, and their diagnosis pointing won’t have anything to do with the extremity at all. Well, that’s an easy denial, because what you’re saying is this extremity adjustment that I did is only related to these diagnosis codes A through D, instead of the actual diagnosis the why that is specifically related to that extremity that you’re adjusting and so that is super important to get that right as well, extended, not just on the adjustment codes, but also on the other services that you’re performing those days as well.

Brandy:
Absolutely.

Marc:
So, diagnosis pointing. But the biggest thing is, this is what we wanted you to be aware that with Blue Cross, Blue Shield of Illinois, if you’re starting to see some denials that aren’t making a whole lot of sense, and they’re indicating that there’s something wrong with your diagnosis codes, you may want to submit a corrected claim. I think that’s right, the right terminology, correct the claim, and making sure that your documentation backs this up, right? So you got to make sure it’s well documented. You can’t just randomly add diagnosis codes, but add the appropriate diagnosis codes related to the segmental dysfunction, or the M99 codes related to those regions that you adjusted

Brandy:
Absolutely, and make sure you’re reading your EOBs. It’s so easy to overlook things. Clinics always say, well, the payer is messing up, and most of the time, and granted, the payers do, because we’ve had this talk before, but much of the time, we can go back and look at the coding guidelines and the patterns in our billing and figure out where we can make improvements and changes to prevent challenges like this that cost us time and cost us money.

Marc:
Yeah, well, we hope this information helps you out, and call us with any questions if you run into these challenges, and we will catch you next week.