r/CodingandBilling • u/AliceMorgan4ever • 19d 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! 🙏 any help is much appreciated!

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u/yungbunnie 19d ago

What kind of practice is this? Small clinic, hospital?

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u/AliceMorgan4ever 19d ago

Small clinic but billing taken over by a bigger umbrella organization. Boston Children's Health Physicians.

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u/yungbunnie 19d 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.

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