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Issue Diagnosis Code - Medical claim from Dental office
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Guest
#1 Posted : Tuesday, January 17, 2017 10:50:56 AM(UTC)
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Guest

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I have filed some medical claims regarding a patient who had an ATV accident in 2013. She is have some work done to replace the teeth she lost.

My first claim I filed 99214 for the exam and 70486 for the CT Scan.

The diagnosis codes I used were
S01.90XS Late Effect of trauma
K08.25 Moderate ATrophy of Maxilla
G50.1 Facial Pain

My second claim I filed 21210 for Bone Graft, Maxilla and 15240 full thickness tissue graft

I used the same diagnosis codes
S01.90XS Late Effect of trauma
K08.25 Moderate ATrophy of Maxilla
G50.1 Facial Pain

I received a letter back from BCBS stating that those diagnosis codes are not valid. It also states to verify that the diagnosis code is correct for the patients condition, that it cantains any required fourth and fifth digits, and is applicable for the patient age and/or gender.

I'm not sure what do do now. Can you help me?

Edited by user Tuesday, January 17, 2017 10:55:45 AM(UTC)  | Reason: I mis-spelled a word
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courtneydsnow
#2 Posted : Tuesday, January 17, 2017 11:02:02 AM(UTC)
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courtneydsnow

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Hi Guest!

No problem we're happy to help.

So starting with the diagnosis codes you used:

S01.90XS actually stands for: Unspecified open wound of unspecified part of head, sequela
K08.25 - Moderate atrophy of the maxilla
G50.1 - Atypical facial pain

So - it may be that the insurer is looking for more specific codes to describe the accident & the patient's condition.

For the RV accident, i'll need a few more details in order to give you the most specific coding options:

1) Was the patient a passenger, the driver, or a pedestrian in the accident?
2) Was it a traffic or non-traffic accident?
3) Were the teeth lost as a direct result of the accident? (i.e. were they knocked out at the time the accident occurred?)

Looking forward to your response!
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Guest
#3 Posted : Wednesday, January 18, 2017 10:03:25 AM(UTC)
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It was actually an ATV accident.

7-27-2013 she was hospitalized for 2 weeks. Trach was placed
8-20-2013 Tracheotomy was removed
9-13-2013 Surgery to unwire jaw
6-5-2014 Released from plastic surgeon. Yes, she lost teeth.

I believe she was the driver and no there was no traffic.
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courtneydsnow
#4 Posted : Wednesday, January 18, 2017 10:19:57 AM(UTC)
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Hi Guest!

Ok great, thank you for the details.....and yes sorry i see that you said ATV and I said RV :)

Here are some ICD-10 coding options for you (depending on what type of ATV it is) for the accident itself:

V86.52XD - Driver of snowmobile injured in nontraffic accident, subsequent encounter
V86.52XS - Driver of snowmobile injured in nontraffic accident, sequela
V86.53XD - Driver of dune buggy injured in nontraffic accident, subsequent encounter
V86.53XS - Driver of dune buggy injured in nontraffic accident, sequela
V86.59XD - Driver of other special all-terrain or other off-road motor vehicle injured in nontraffic accident, subsequent encounter
V86.59XS - Driver of other special all-terrain or other off-road motor vehicle injured in nontraffic accident, sequela

As for the loos of teeth, here are some ICD-10 coding options for you:

K08.411 - Partial loss of teeth due to trauma, class I
K08.412 - Partial loss of teeth due to trauma, class II
K08.413 - Partial loss of teeth due to trauma, class III
K08.414 - Partial loss of teeth due to trauma, class IV
K08.419 - Partial loss of teeth due to trauma, unspecified class


There may some additional diagnosis codes to use for this case, depending on the patient's condition. (i.e. the atrophy & atypical facial pain codes could certainly apply). Or for example, if the patient also has fractured teeth, you may use one of the following:

S02.5XXD - Fracture of tooth (traumatic), subsequent encounter for fracture with routine healing
S02.5XXG - Fracture of tooth (traumatic), subsequent encounter for fracture with delayed healing
S02.5XXK - Fracture of tooth (traumatic), subsequent encounter for fracture with nonunion
S02.5XXS - Fracture of tooth (traumatic), sequela

(FYI, i did not include the "initial encounter" ICD-10 coding option in the accident or fracture codes, as the initial encounter would have been with the hospital).

Hope this helps, have a great day!
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Guest
#5 Posted : Wednesday, January 18, 2017 10:46:18 AM(UTC)
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I APPRECIATE YOUR HELP SO MUCH!I will give these codes and try and see what I can can get from the insurance.

Have a great day!
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Guest
#6 Posted : Wednesday, January 18, 2017 11:26:19 AM(UTC)
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I need more help, can you help me determine what code to use for the partial loss of teeth?

K08.41 through K08.419
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Guest
#7 Posted : Wednesday, January 18, 2017 11:47:23 AM(UTC)
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Message was deleted by a Moderator. | Reason: Not specified
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courtneydsnow
#8 Posted : Wednesday, January 18, 2017 1:23:43 PM(UTC)
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Hi Guest!

No problem - are you asking how to determine what class the patient is?
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