Wiki M25.50 ICD 10 code being denied by carriers

[nan.coder]

Our Rheumatologists have been using M25.50 to report multiple joint pain for years. Anthem and UHC have started denying claims because diagnosis not reported to the highest specificity. The providers are reluctant to have to click on five or more diagnoses. Their reasoning is a new patient presents for evalution of pain in multiple joints. The exam is performed plue labs and X-rays are ordered. At the end of the visit there isn't a specified diagnosis because test results are not completed.

Are other office experiencing these denials? How are you assigning ICD 10 code for multiple joint pain.

Thank you,
Nancy Boyle, CPC CRC

 

[sls314]

Our Rheumatologists have been using M25.50 to report multiple joint pain for years. Anthem and UHC have started denying claims because diagnosis not reported to the highest specificity. The providers are reluctant to have to click on five or more diagnoses. Their reasoning is a new patient presents for evalution of pain in multiple joints. The exam is performed plue labs and X-rays are ordered. At the end of the visit there isn't a specified diagnosis because test results are not completed.

Are other office experiencing these denials? How are you assigning ICD 10 code for multiple joint pain.

Thank you,
Nancy Boyle, CPC CRC

M25.50 does not indicate pain in multiple joints - it specifically denotes pain in an unspecified joint. In other words, it tells the story that “the patient has joint pain, but who knows which joint?”

If the provider knows which joint(s) are affected, then you should report the appropriate, specific code(s) for those location(s). Even if that means assigning more than one diagnosis code.

Many payers have begun implementing policies that deny unspecified codes when greater specificity should be available. You’ll likely see increasing denials going forward as additional payers activate edits for unspecified codes. Now that they have the technological ability, payers are getting savvier about applying edits for coding guidelines.

It will never go back to the day when they could just throw M25.50 on a claim and call it good because they didn't feel like assigning multiple (more accurate) codes.

It’s best to address this now and get them in the habit of reporting the most specific codes available for more accurate and compliant claims.

 

[jkyles]

I would just add that the providers might be getting "not otherwise specified" confused with "unspecified," so a little training on that might be useful.

Also, for whatever reason some payers list unspecified codes in their policies, even though they won't cover them.