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Posts Tagged ‘coding’

We blame insurance companies for denying claims.

While they are mostly at fault, there are times when the denial is justified.

I filed an out-of-network claim for a client. I looked at all the numbers that have to be on the claim, and they were all there and looked fine. So the claim was filed.

The insurance processed the claim and paid a very small portion of it. That prompted me to take a second look.

It turns out that the diagnosis code on the claim is unspecified gout. The services were an office visit, aspiration (taking fluid out), injection, and a substance that was injected.

The insurance paid for the office visit and nothing more. In this case I cannot blame the insurance. The diagnosis code told them about a gout, but no code to justify the aspiration or the injection. So, I am going back to the doctor and asking about the details and, very importantly, the location of the injection and the location of the aspiration. I would guess that those may have been in two different places, such as a shoulder and elbow.