Medicare non coverage due to incorrect diagnostic code on claim

Posted by caretakermom @caretakermom, Sep 4 6:30pm

Hi everyone,
My husband is about 6 months post kidney transplant which he received from Mayo Clinic Az. He has Medicare as his primary and employment insurance as secondary. Thus far, there are 3 lab tests that Medicare denied coverage and for which he did sign ABNs. Medicare denied coverage because the code submitted on the claims did not indicate medical necessity(even though these tests were standard tests ordered for post transplant patients). Upon closer scrutiny, I discovered that the labs were originally ordered with the wrong codes, codes that are too general to convey specific medical conditions. Unfortunately, our nurse coordinator says these tests were ordered months ago, and neither she nor her staff ordered them. Apparently, the order was put into the system by another department and these are all standard orders for post kidney transplant patients.
I'm having a devil of a time getting Mayo to correct these codes, no one seems to know what is the proper procedure and which department is responsible to make the change. I have called billing many times and they say they cannot make any changes. They directed me to the Records and Amendment Dept and the lady there says she's not the one to make the change either. The nurse tried to do it via the patient chart on Epic but the changes she put in got reversed overnight by the software. So Epic is not updating it either for whatever reason(probably due to IT issues). I have spoken with the provider office(nurse coordinator) she gave me the corrected ICD-10 codes to use for the non covered claims but I'm unable to find anyone at Mayo who can help me resolve this issue. Just FYI, billing is inert because they go by what is on the original order. Does anyone have any idea who I can call for help? Is there a patient advocacy program I can talk to? I just don't understand why they can't make changes to the codes, even though we have support from the provider office. Error in coding happens often and there should be a way to resolve!! Suggestions/advice welcome. Looking forward to hearing from you!!

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@jennifer0726

Hi @caretakermom, I did not have 24 hour ambulatory BP monitoring at my 4 or 12 mo. visits. My BP is usually good. I live out of state, too, in IA and tx in MN. I had a pre-emptive living donor tx, and didn’t do dialysis thankfully. Billing errors can happen for anyone, but usually for me now and over the years at local providers I can get them resolved.
@gingerw It is great that your phlebotomist is so aware and caught those wrong codes!
My main local lab is where they told me Medicare never pays for Vit D etc. tests and wanted me to sign a waiver saying I would pay full price! I didn’t because they had a contractual relationship with BCBS and are required to accept what they determine my co-pay or co-insurance to be unless it is a non covered charge. I also plan to work past 65 if I am able, as I prefer to be able to keep my private insurance and it will increase my future pension. I took Medicare A & B as I was told if I didn’t they wouldn’t cover the tx meds after I turn 65 under part B. I still pay my BCBS premiums, deductible & co-pays/co-ins, too. Cost of living in IA is much less than CA, and my income is most likely way less and that is why I pay the basic $170.10 per mo. Medicare premium for part B. For me, it is expensive on top of everything else being single. I am thankful to work for the State and to have good benefits. I hope you can get your coding issue solved!

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Hi @jennifer0726, the ambulatory 24 hr bp monitoring test is a standard test Mayo Az orders for all patients in their 4 month post kidney txplant follow up which includes a biopsy. As I understand it, the 1 and 2 year follow up are similar to the 4 month follow up. So you are probably lucky your Mayo team didn't order one for you. All of the coding issues/Medicare non coverages we have incurred thus far(this is hubby's 2nd year on Medicare) are with the Mayo Az campus and they stem from labs that were ordered by the Mayo Az providers and done at Mayo Az. We were not told ahead of time whether a test is optional so when we show up for labs, we just assume it's medically necessary. By virtue of the Mayo provider ordering these labs, you would think the they are medically necessary!! You are right in that coding errors wrt to Medicare occurs often and it is not unusual for providers to make corrections. But for some reason it's is extremely difficult to make code corrections with Mayo Az, even when you have the provider's support to make the coding change!!! Thanks for your input!

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@jennifer0726

Hi @caretakermom, I did not have 24 hour ambulatory BP monitoring at my 4 or 12 mo. visits. My BP is usually good. I live out of state, too, in IA and tx in MN. I had a pre-emptive living donor tx, and didn’t do dialysis thankfully. Billing errors can happen for anyone, but usually for me now and over the years at local providers I can get them resolved.
@gingerw It is great that your phlebotomist is so aware and caught those wrong codes!
My main local lab is where they told me Medicare never pays for Vit D etc. tests and wanted me to sign a waiver saying I would pay full price! I didn’t because they had a contractual relationship with BCBS and are required to accept what they determine my co-pay or co-insurance to be unless it is a non covered charge. I also plan to work past 65 if I am able, as I prefer to be able to keep my private insurance and it will increase my future pension. I took Medicare A & B as I was told if I didn’t they wouldn’t cover the tx meds after I turn 65 under part B. I still pay my BCBS premiums, deductible & co-pays/co-ins, too. Cost of living in IA is much less than CA, and my income is most likely way less and that is why I pay the basic $170.10 per mo. Medicare premium for part B. For me, it is expensive on top of everything else being single. I am thankful to work for the State and to have good benefits. I hope you can get your coding issue solved!

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Hi @jennifer0726, hope it's OK to PM you. Please check inbox!

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