06/09/2022

BlueCross Denials for E&M’s- ChildHealth Plus Medicaid

I have just started getting denials for E&M codes, that I have never seen before, from BC/BS Anthem HealthPlus. For example, I evaluated a 3 month old child, accompanied by his mother, with a chief complaint of a congenital deformity of toes on both feet. The patient was referred by the pediatrician. I spent over 45 minutes with the child and parent. a full H&P of the lower extremity was performed. I discussed the etiology of the condition along with conservative and surgical management options for treatment. I taught the parent how to strap the affected toes and applied the strapping to both feet. Follow up was discussed. Report sent to PCP. The billing/claim was as follows: Diagnoses... M20.5X1 Other deformities of toe(s) (acquired) right foot M20.5X2 Other deformities of toe(s) (acquired) left foot Q66.89 Other specified congenital deformities of feet Treatment... 99203 E&M Low Complexity The claim was denied with the following reason codes: CO-16: Claim/services lacks information or has submission/billing errors M76: Missing/ incomplete/invalid diagnosis or condition I can only suspect that the insurer's claim processing system did not like ICD.10 codes that are both Congenital and Acquired. However, there is no accurate/specific ICD.10 code that accurately describes the deformities of the toes. The other diagnoses used are more specific to the patients condition. I have never had a problem billing such combinations with this insurer in the past. Also, quite often super structural congenital orthopedic deformities can cause acquired conditions in patients feet. WHAT IS WRONG? Just like complications of systemic diseases can cause conditions in the feet. I will give you one more example of an E&M code denied with the SAME reason codes as above. 7 year old child with a congenital condition that caused an acquired condition in the feet. Diagnoses: M21.071 Valgus deformity, not elsewhere classified, right ankle M21.072 Valgus deformity, not elsewhere classified, left ankle M72.2 Plantar fascial fibromatosis M77.41 Metatarsalgia, right foot M77.42 Metatarsalgia, left foot M79.671 Pain in right foot M79.672 Pain in left foot M79.672 Pain in left foot Q66.51 Congenital pes planus, right foot Q66.52 Congenital pes planus, left foot R26.2 Difficulty in walking, not elsewhere classified Treatment: 99213 The claim was denied with the following reason codes: CO-16: Claim/services lacks information or has submission/billing errors M76: Missing/ incomplete/invalid diagnosis or condition

Since both patients listed in the inquiry are members of the same Child Health Plus Medicaid plan, they very likely denied the claim for similar reasons. When an insurance like Blue Cross denies any code with M76 (Missing/incomplete/invalid diagnosis or condition), the diagnosis code is valid, but is not payable per the patient’s benefits, even if medical necessity can be proven with the documentation. Based on the diagnosis codes listed, Blue Cross could be denying the office visit because the Q66.XX diagnosis codes, since they are considered routine. However, to confirm, it would be recommended to contact the claims department about the denial and ask them which code specifically caused the CPT to deny for the missing diagnosis or condition so the corrected claim can be sent to Blue Cross for processing.