We have a claim denial from a commercial insurance plan that references their policy related to Excludes 1 Notes based on the ICD10 Official Guidelines for Coding & Reporting. OT and PT used codes R26.2 (difficulty in walking) and R26.81 (unsteadiness on feet) as the ICD10 codes. This has never been a problem before. We’ve checked with the physician and our codes are valid. How can we get this claim overturned?
Early on in ICD-10, most payers implemented a moratorium on ICD-10 edits to allow providers time to adjust to the new rules. While some healthcare sectors began seeing ICD-10 edit applications as early as 2016-2017, therapy was seemingly left untouched – until now. Therapy providers are starting to see payment edits in place that trigger automatic claim denials due to ICD-10 codes. Unfortunately, the combination of two of the most common ICD-10 treatment codes – R26.2 difficulty walking and R26.81 unsteadiness on feet – stand ripe for denials when paired together on the claim form. According to the ICD-10 Coding Guidelines, excludes notes indicate that codes excluded from each other are independent of each other. An Excludes1 note means “NOT CODED HERE” and should never be used at the same time. The ICD-10 coding manual lists R26.81 unsteadiness on feet and R29.6 falling as an Excludes1 note under R26.2 difficulty walking.
Therapists should not pair these two codes together on the therapy plan of care given the official coding guidelines and high risk for denial. Often, however, R26.81 unsteadiness on feet may be appropriate to support the OT treatment while R26.2 difficulty walking is appropriate to support the PT plan of care. In these cases, collaboration with the billing office through triple check is essential to approach the revenue cycle proactively.