11: The diagnosis is inconsistent with the procedure

On Call Scenario:

                                                 Claim denied as diagnosis code is
                                                   inconsistent with the procedure
                                                                           ↓
                                                        May I get the denial date?
                                                                           ↓
                                         Could you please tell me which diagnosis code
                                     is inconsistent (If there are multiple DX code coded)?
                                                                           ↓
                                           Check patient payment history if the same 
                                                   DX code paid with same CPT
                                               ↙                                                     ↘
                                         Yes                                                           No
                                           ↓                                                              ↓
              Can you please reprocess the claim as                What is the time limit to 
            payment received for same CPT & DX?                send corrected claim?
                                           ↓                                                              ↓
                  What is the TAT for reprocessing?                What is the Fax# or Mailing 
                                           ↓                                             address to send an appeal?
                  May I have the claim# & call ref#?                                 ↓
                                                                                       How much is the time limit 
                                                                                              to send an appeal?
                                                                                                           ↓
                                                                                    May I have the claim# & call ref#?

Important Note:

• This denial should be assigned to the coding team to review and provide the correct dx code and once a response is received with the correct dx details then submit the corrected claim to insurance by updating the correct dx code if the time limit to submit the corrected claim is not crossed.
• Sometimes the client wants us to submit the corrected claim even if the time limit is crossed, so work accordingly.
• If the coding team states that the dx code is correct then send an appeal to insurance.
• When sending an appeal, calculate the time limit from the denial date, if it is not crossed then send the appeal, or else write off the claim if the time limit is crossed.
• Sometimes the client wants us to send the appeal even if the time limit is crossed, so work accordingly.

Prepare Notes:

Source of Status:

* Call Website EOB System

Clearing House Comment (Please make the changes if required):

Insurance Name:

*

Clearing House Name:

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Denial Date:

*

Has rep provided inconsistent DX?:

* Yes No

Mention inconsistent DX?:

*

Has payment found for the same CPT with same diagnosis code in the patient payment history?:

* Yes No

What Information is Available?:

* Corrected Claim Time Frame Appeal Information Corrected Claim Time Frame and Appeal Information None

TAT for Reprocessing:

*

Corrected Claim Time Frame:

*

Mode of appeal:

* Fax Mail Website

Fax Number:

*

Mailing Address:

*

Website Link:

*

Appeal Limit:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Need coding assistance Updated correct DX and resubmitted the claim Updated correct procedure and resubmitted the claim Need client assistance Need to send an appeal Need to allow time Appeal Sent



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