DecisionHealth, DecisionHealth - 2023 Issue 7 (July)
Q&A: Here’s how to address payer policies that are based on improper coding
Question: We are being told by our internal insurance rep that Humana and Humana Advantage will not allow or pay for an E/M if we do not bill the chief complaint as the diagnosis. Our rep is saying that Humana will pay for pain in wrist (M25.53-) but not for a distal radius fracture (S52.5-). We are also being told that this applies for patients that are following up for the problem. Basically we are being told we cannot use the S codes at all for E/M office visits with Humana. This just does not make sense to me. If a provider just has an E/M or E/M and X-ray and no other procedures (fracture care, etc.), there would be no way to report a fracture or other injury (S codes specifically).
I have tried to find a policy on Humana's websites, but all I can find is where they state that the most definitive diagnosis known should be used. I have also asked our insurance rep to please provide the policy that Humana is using for the denied claims along with examples of the denials and EOBs. How would you handle this situation?
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