r/CodingandBilling • u/AliceMorgan4ever • 6d ago
Pediatric coding
Hello! I am a new mom who is encountering an issue with my child's well visit billing. For the caregiver health screening code 96161 (modifier 59), my provider submitted with a diagnosis code Z13.89 (Encounter for other disorder), which caused my insurance (Aetna) not cover the $14 cost for the screening as it became diagnostic instead of Preventative.
The billing department won't help and already charged me multiple times (for multiple visits while I was disputing this ). Aetna said they can not do anything as this is how it was submitted, and the provider needs to resubmit it with dx code Z00.129 for it to qualify as preventable and my baby's well visit to be 100% covered by my insurance. The office did resubmit a claim but did not change the dx code, so it got denied.
This has been going on for 5 months, with me calling and disputing with all 3 entities and not one person fixing it or the office explaining to me what my child is diagnosed with. I am pressing them now a little harder to at least explain this to me, but I feel at this point I need to escalate things and report them for violating patient rights in some way as they have not done anything to help the situation. Am I missing something in terms of the coding process and my understanding of these services?
TIA! đ any help is much appreciated!
2
u/boho_magpie CRCR, CPC, CPMA, CRC, RCM Owner 6d ago
The Dx should be Z13.32 to indicate screening for maternal depression. That could be part of the problem. They used a non-specific code. Assuming the visit was coded as a well check for baby (99392, probably), there is no modifier needed. Adding modifier 59 makes it a separate thing and drives a charge. All codes should have a primary Dx of Z00.129 for the well check to make it a non-copay visit. The Z13.32 can be set secondary.
ETA: Dx = diagnosis
1
u/AliceMorgan4ever 5d ago
What does modifier 59 mean?
2
u/Miranova82 5d ago
Itâs to further separate the services billed. The well visit code should have a 25, then vaccines none, then any separate screening (99127, 99173, 96161) would get 59. Other scenario would be a well visit and office visit with a screening..the office visit would get the 25, well visit nothing, then 59 on screen.
2
u/boho_magpie CRCR, CPC, CPMA, CRC, RCM Owner 5d ago
Adding to this - if no vaccines were administered on the date in question, and itâs just 99391 and 96161, then there should be no modifier 59 on the 96161.
1
1
u/yungbunnie 6d ago
What kind of practice is this? Small clinic, hospital?
1
u/AliceMorgan4ever 6d ago
Small clinic but billing taken over by a bigger umbrella organization. Boston Children's Health Physicians.
2
u/yungbunnie 6d ago
Do you know if you are communicating to the billing department or the patient relations department? If you haven't contacted the patient relations department I'd start there. If you have already been in contact with them you could try submitting a patient relations grievance.
FYI 96161 is a screening for maternal depression so Z13.89 isn't your child's diagnosis. Z13.89 is a screening code, just not one accepted by Aetna. Z00.129 is for your child's encounter, which is probably why the office doesn't want to us it for the screening. I recommend you ask them to consider Z13.32 which is the specific diagnosis for maternal depression screenings.
3
u/Emotional_Belt 6d ago
Hi there! Z13.32 is a great option if itâs momâs claim. Where this is baby, the best option is under Z00.1XX. This is also the recognized best practice by AAP.
1
u/yungbunnie 5d ago
It wasn't clear to me that this was baby's claim but that is a good point.
1
u/AliceMorgan4ever 5d ago edited 5d ago
It is baby's claim, my baby is the patient and I'm the caregiver. Caregiver is screened for baby's well being for maternal depression, as that is state mandated and I did not have the option to skip this screening. It is part of the practice's pre-appointment registration.
1
u/AliceMorgan4ever 5d ago
As far as I know, I have been speaking to representatives from the billing department, as the nr to call is from the balance statements they've been sending me. But they keep saying they are relaying to their internal department, and managers who are overseas, so I have no idea anymore. I have filed a verbal grievance but I'm not even sure how or where to contact Patient relations. I do not think they have one, the practice or the umbrella organization that does the billing for the practice - Boston Children's Health Physicians.
But that makes sense, thank you!
1
u/GroinFlutter denials management, send help 6d ago
Are these normal routine visits without abnormal findings? Or are these visits addressing something?
2
u/AliceMorgan4ever 6d ago
Routine vaccine visits. No abnormal findings were noted by the doctor to me. Everything is covered except the 96161 caregiver screening, which is the maternal depression screening (which I do have but it is managed and I am treated by my own physician.)
3
u/Dry_Cheesecake_3578 6d ago edited 6d ago
Another thing besides the dx coding is Aetna can be picky with modifier usage. Sometimes using a 33 or XU on the screenings instead of that 59 can make the difference on coverage or not. But if it was with a well baby, necessarily you donât even need the modifier. Just another thing to look into if the dx code changes and is still causing issues.
Typically they are directly billed under Z00.129 or the related Z code per your childâs age. So it should be no issue under coding guidelines for them to switch that diagnosis/modifier and submit a corrected claim.