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Deferred Diagnosis (R69)

Sheryl Martin 3 years ago in Billing/Electronic Modules updated 3 years ago 9

I did an analysis of billed R69's to see who was paying them. (These are generally a first appointment with a parent only--90846.) We have been paid for this diagnosis by Health Partners, PrimeWest, BCBS, Preferred One and America's PPO. We have not been paid by Medica or MA. Their denial description states "Diagnosis not consistent with procedure".


Is anyone billing this as a Z71.1 or a Z03.89? Are you being reimbursed by Medica and/or MA? Thanks in advance!


Sheryl

You can try billing the individual therapy codes instead of the family codes. As long as the session focuses on the child and their mental health treatment you can bill the individual therapy codes (ex: 90837)

Also, to bill the 90837, the child must be present for a significant amount of the billed time.

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Thank you, Caryn.  Any idea about the diagnosis though?  Particularly when the parent never reappoints, it is difficult to make a diagnosis, so we've been using the deferred.  Thanks!


Sheryl

Sheryl,  I do not have a follow up on your original question about billing Z71.1 or Z03.89, but I do have a question about billing an R69.


When we first started using Procentive, our trainer helped set up the R69 code as "Diagnosis Deferred" in order for the claims not to send without a Dx.  

Recently, we had a client using EAP services, and the only way for the claim to be sent without a Dx, was to use R69.  


I ended up switching the Diagnosis R69 in our Procentive from not billable to billable.  Then billed out only claims for the said EAP client, and had to go back to the R69 and switch back.  It was a tedious process.


With that being said, what are others billing when a Dx is not required and sending claims electronically?  

Or what are other facilities using when the clinician doesn't yet have a Dx?


When a clinician doesn't quite have a diagnosis yet for a service line, we set up a dummy diagnosis code of 000.00 in our system and attach that to the service line. This allows us to enter the service line but not allow us to bill it to any payer.  Then once the clinician determines the diagnosis code, they go in and update the clients account to he actual diagnosis code.


We only bill the R69 diagnosis code when a clinician is not able to determine a diagnosis on the client.  Some get paid some do not as Sheryl stated with her original comment as it just depends on the insurance company you are billing.

This is helpful, thank you ahuseby for your response!



For those clients with not diagnosis after completing a DA


CODE WHEN THERE IS NO SERVICES DUE TO DIAGNOSIS

 

ICD-9

V71.09 (Diagnosis- Mental disorder not present.)

 

ICD-10

Z03.89 (Diagnosis- Mental disorder not present.)

 

FYI-

Dwight  from DHS mentioned to use this diagnosis code when there’s not a basis for continuing

Mental health services.

Would you use this R69 dx code if the client came in for 1 visit and never returned before a diagnosis could be established?

Rochelle, 

That is what we have been doing.  I will need to look and see how that's worked out for us!


Sheryl