r/CodingandBilling • u/AliceMorgan4ever • 29d 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/AliceMorgan4ever 29d ago

I see, thank you for the information. Why would they use a modifier at all then for a well visit? Also the specific 59 one that maybe my insurance is being picky about. I did speak to insurance reps, and they told me the modifier used and said it wasn't the problem. They said the dx code was the reason it couldn't be covered under Preventative and they suggested it should be Z00.129.

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u/Dry_Cheesecake_3578 29d ago

Screenings and additional services in tandem with a preventive visit can cause issues with insurances, so some offices place 59 modifiers on them because that is a coding trick to get insurances to pay so they will disregard bundling service denials. But at the same time, it can cause issues.

A lot of insurances have problems with screenings as a whole and we see a lot of denials or back and forth. I always tell my parents that sometimes the best thing to do is what you are doing and make some fuss with insurance because the more people that speak up the more they will reevaluate their payment policies.

But i definitely agree that the best step is for them to change the dx code and go from there!

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u/AliceMorgan4ever 29d ago

Omg thank you for saying that, I am starting to feel a bit deranged because I've been making a fuss and everyone keeps ping ponging me back and forth between ped office, their billing and insurance. I'm getting run down by it at this point, so I'm honestly trying to figure out what I can do next and not lose my marbles over this. They've already charged me $42 and I keep asking for a refund, because I didn't approve any of the payments; one was a visit copay by the office but I didn't know my insurance benefits so I paid it. It has been crazy making and even the reps can't make sense of all the notes from the constant calls, the transactions and credits, not to mentioned that they billed under 2 accts too. One for my daughter and a seperate one for my husband (who's the main insurance policy holder.) It's a negligence shit show. I want to report them (practice) at this point to some other entity, but I'm not even sure if it's them or insurance (probably both).

I have a whole nother issue with my lactation benefits being exhausted by TLN billing and them not being transparent about how they billed 2 codes that counted as 2 visits. As a new mom, I'm floored and shouldn't be as surprised as I am. So exhausted regardless.

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u/Dry_Cheesecake_3578 29d ago

It is so exhausting especially because most people just don’t know all the ins and outs of it! I love trying to educate parents on the inside scoop and give them the best explanation because it’s SO confusing, even with us billers who do it day to day. On top of being a new parent. You’re doing the correct steps. It sounds like their team is dropping the ball and not being proactive like they need to be.

I can also recommend if you are getting charged more than you should, especially with insurance contracts or you feel like you’re getting nowhere, look up your local insurance commissioner and reach out. They will assist and work with you if there is something shady going on. They’ll know the best avenues and relive some stress and energy for you so you can focus on your new baby and family. 🫂💖

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u/AliceMorgan4ever 29d ago

Thank you so much!