Caresource being Caresource

medicaid-ga-policy-reimburse-py-1428-20260201.pdf

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Recently, as most have seen by now since I'm late getting this out, CareSource has been denying claims that have a primary unspecified diagnosis code. This was an old rule that was put in place long ago when ICD10 first came out. 

You should never ever use an unspecified diagnosis code as a primary diagnosis. Therapists should use a specific diagnosis code from the evaluation as primary. Here are some examples and exceptions: 

Child evaluated for OT, has fine motor delay, diagnosis of CP from pediatrician: 

Can be listed as: 

1. F82

2. G80.9

   Or 

1. M62.81

2. G80.9

The description of G80.9 is: 

Cerebral palsy, unspecified

The key word here being unspecified. 

Here's another example:

Child is evaluated for speech. Therapist states in evaluation it's a delay.  The diagnosis needs to be specific to be primary: 

1. F80.0

   Or

2. F80.2

Can't use F80.9 because this code states: 

Developmental disorder of speech and language, unspecified

Can't use R62.50 because: 

Unspecified lack of expected normal physiological development in childhood

But could use: 

R62.0 

Delayed milestone in childhood

I've heard feedback from therapists stating, we have to use what the dr puts on the Rx. WRONG. 

The dr is sending the child to you to get a diagnosis. You're performing an evaluation to determine a diagnosis. The dr is signing off on your plan of care that states what you're saying the diagnosis is.  Dr offices simply put down whatever generic diagnosis code on purpose to fulfill the need of having something until it's determined by the evaluation. 

On other news with Caresource, as of February 1st, they will be reducing payment for multiple therapies being seen the same day just like Peachstate. With that being said, let me remind everyone that it is important for providers to complain to DCH when there is a problem with a CMO so that it's recorded for the purpose of contract renewals.