If you are not familiar with the details of billing, it is a nationally standardized process regardless of the payer. All claims, except when in the hospital, must be submitted on a HCFA 1500 form.
The above photo is an example of one. They are printed in red ink for scanning purposes. We are an electronic filer so we are not actually sending this paper form to the insurance carrier, rather the data is submitted electronically, but it must be in the above format so if the end user wants to print it out, the appropriate boxes are aligned. Much of the data is personal info such as name, address, birthdate, insurance number etc...
...until you get to box number 21. That is where the diagnosis is identified. This diagnosis should only be for the treatment for the date of service. This is where the PROBLEM usually starts.
This is the master ICD-9 book. There are thousands of diagnoses to pick from and the key to successful claim payment is to choose the correct one(s) for the treatment of the day. For some reason many medical offices including physical therapists, speech therapists etc. want to put 758.0 as the first DX(diagnosis) code.
As you can see 758.0 is the code for Down's syndrome (yes they still use the "s"). That is almost always NOT CORRECT and is a flag to many insurance carriers to DENY the claim.
Using Sarah as an example, her diagnosis on a visit could be...
493.2 Chronic Obstructive Asthma. Yes it may seem to be more common in kids with Ds, but millions in the general population also have COA.
same goes for 518.81 Acute respiratory failure
even 519.00 tracheostomy complication
and the big one 745.4 ventricular septal defect. All of these diagnoses could be denied if it is accompanied with 758.0
Think like this...the insurance carriers have massive computerized systems in place to DENY your claims. It is like a flow chart, if this dignosis comes in with this diagnosis DENY the claim. Almost always the first denial is simply made by a computer. No human has reviewed the claim. Same with the first refile.
So how do you avoid this potential problem? Stop at the desk on your way out of the medical office and just say, "I want to make sure when this visit is billed that it not include 758.0. This is especially true when billing for private speech. Most carriers have very limited coverage, if any, for speech delays related to a "chromosomal anomalies" or "genetic disorders". Once 758.0 gets into the insurance carriers system, denies will become the norm.
Look at it like this, with speech therapy you are not treating the Down syndrome, you are treating a language delay, so why would you use 758.0. With physical therapy, you are not treating the Down syndrome, you are treating a gait abnormality. With a bunion, you are not treating the Down syndrome, you are treating the bunion.
I hope this helps. If you have a specific question, send me an email and I will give you my best lay advice.