MOCK CALL-DX code is inconsistent with the CPT code

James is AR CALLER Calling from India to USA insurance live rep in order to check the claim status the rep’s name is Sandy.
James Dialed the number 899-862-3220 (United Health Care).

Sandy: Thanks for calling this is Sandy how may I help you today?
James: Hai my name is James I am calling from the doctor’s office and I would like to check the claim status for a patient.
Sandy: Which doctor’s office you are calling for?
James: I am calling for General Orthopedic Associates
Sandy: And what is your telephone#?
James: My telephone# is 1800-999-9999
Sandy: What is the patient social security#(SSN)?
James: The social security# is 123-456-789
Sandy: Could you please hold for a moment I will pull up the patient’s records
James: Yes, please
Sandy: What are the patient’s name and dob?
James: The patient’s name is Linda Far and her DOB is 26/11/1995
Sandy: What is the date of service you checking for?
James: The DOS is 03/02/2021
Sandy: What is the billed amount on this claim?
James: The billed amount is $1500.00

Upon verifying the claims history, If the same DX code & CPT code combination was NEVER paid on the previous DOS, now what will you do?

Sandy: Could you please hold for a moment I will search for the claim?
James: Yes Sandy take your time!
Sandy: Thanks for being on holding James, Claim denied for the diagnosis code is inconsistent with the CPT code
James: Okay, May I know the claim received date?
Sandy: Claim was received on 03-15-2021
James: May I know the claim denied date?
Sandy: Claim was denied on 03-20-2021
James: Could you please tell me which diagnosis code is invalid?
Sandy: The primary dx code z94.0 is inconsistent
James: could you pls hold for a moment to find more information on this code
Sandy: Okay
James: Thanks for being on hold, Sandy can we send a corrected claim?
Sandy: Yes
James: What is the corrected claim address and timely filing limit?
Sandy: The cc address is PO BOX 740805 SALT LAKE CITY UT 84133 and the timely filing limit is 120 days from the date of denial
James: Also for my documentation purposes can I get the appeal address and timely filing limit?
Sandy: The appeal address is PO BOX 30669 SALT LAKE CITY UT 84133 and the timely filing limit is 90 days from date of denial
James: Thanks Sandy may I get the claim#
Sandy: Yes it is ABC1258
James: What is the call reference # Sandy?
Sandy: yes James is it my name and today’s date
James: Thank you so much for your information it is nice talking to you have a nice day Sandy
Sandy: It’s pleasure talking to you James, you have wonderful rest of your day.
Jame: BYE.

NOW GET ASSISTANCE FROM CODING TEAM TO FIND CORRECT DX CODE, once the coding team appended the correct dx code then send the CORRECTED CLAIM.

James: Thanks for being on hold, Sandy can we send a corrected claim?
Sandy: Yes
James: What is the corrected claim address and timely filing limit?
Sandy: The cc address is PO BOX 740805 SALT LAKE CITY UT 84133 and the timely filing limit is 120 days from the date of denial
James: Also for my documentation purposes can I get the appeal address and timely filing limit?
Sandy: The appeal address is PO BOX 30669 SALT LAKE CITY UT 84133 and the timely filing limit is 90 days from date of denial
James: Thanks Sandy may I get the claim#
Sandy: Yes it is ABC1258
James: What is the call reference # Sandy?
Sandy: yes James is it my name and today’s date
James: Thank you so much for your information it is nice talking to you have a nice day Sandy
Sandy: It’s a pleasure talking to you James, you have wonderful rest of your day.
Jame: BYE.

WHY appeal address?
because if the coding team checked and said that the already billed DX code and CPT code is correct and no need to change it, in that case, we need to send an appeal.

Upon verifying the billing summary, If the same DX code & CPT code combination was already paid on the previous DOS, now what will you do?

Sandy: The primary dx code z94.0 is inconsistent
James: Could you pls hold for a moment to find more information on this code
Sandy: Okay
James: Thanks for being on hold, Sandy upon checking the patient’s billing history, found payment for this same Dx and CPT code combination
Sandy: Pls provide me the DOS
James: Yes it is 01-15-2021
Sandy: Let me check pls hold for a moment
James: Okay
Sandy: Thanks for being on hold, James yes you are right this dx and CPT code combination was already paid!
James: Could you pls send this claim back for reprocessing with reference to the paid one?
Sandy: Yes pls be on hold James
James: Okay
Sandy: Thanks for being on hold, James I have sent back for reprocessing so kindly allow 15 business days
James: Thanks Sandy may I get the claim#
Sandy: Yes it is ABC1258
James: What is the call reference # Sandy?
Sandy: Yes James is it my name and today’s date
James: Thank you so much for your information it is nice talking to you have a nice day Sandy
Sandy: It’s a pleasure talking to you James, have wonderful rest of your day.
Jame: BYE