Rule 25 Diagnosis codes

mboron 7 years ago in ICD-10/DSM5 updated by Kim Ross 7 years ago 6

When providing a Rule 25 and billing H0001, if the client does not have a Substance use disorder, what DX code are you using on the claim in order to get the service provided paid.  We have used Z65.8, BCBS is denying it stating it is not a Chemical Health DX code.



Thank you, I will try it.

The current president of the American Psychological Association, Tony Puente, Ph.D., is an authority on CPT coding. He was the behavioral representative (the only one) on the committee that governs CPT codes.  I viewed a webinar that he provided about CPT issues a few weeks ago. While reviewing 90791, he explained that it is not unusual to do a diagnostic assessment and find that that the patient does not have a psychiatric diagnosis, and this is good for the patient but creates a question for the clinician about how to bill for the service.  Dr. Puente advises to "bill for what you were looking for, not what you found."  In other words, of the patient was referred for a Rule 25 Assessment due to concerns about alcohol problems, and the outcome of the assessment was no diagnosis of an alcohol disorder, you would probably bill for Alcohol Abuse.  

One more thing- Dr. Puente's advice about how to bill changes after the DA. He explained that there is a difference between a DA, which is assessing the need for treatment, and subsequent therapy appointments, which of course are providing treatment  - and this requires a diagnosis.  His advice, summarized for DAs and therapy, is: "for DAs, bill for what you are looking for, and for therapy bill for what you found."  Of course, if the outcome of the DA is no psychiatric diagnosis, then you cannot bill for subsequent therapy  sessions (due to a lack of medical necessity for treatment).  You can still bill for a DA which did not result in a diagnosis, as the purpose of the DA was medically necessary (to assess whether treatment is needed).  At least that is my understanding. 

Well BCBS does not have a "No Diagnosis" code for SA for when crosswalking ICD-9 to ICD-10 of V71.89 to Z03.89, because of the role out of there new computer software program they elected to associate Z03.89 with a different diagnostic classification and stated their system will only allow for 1 classification or a 1:1 crosswalk ratio.  Currently, we have to send all of our denied BCBS claims due to the Z03.89 Dx and have Larry Payton manually re-submit the claims.  BCBS could not identify ANY Dx code they would accept.  BCBS is not motivated at this time to find a fix.

Any news on whether or not the BCBS situation you described still exists? Have they fixed the problem?