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Q/A: I am Having Trouble with a Claim Rejection on my PI Claim. What do I do?

By:  Wyn Staheli, Director of Research
Published:  April 12th, 2018

Question:

I have a patient that was involved in a PI case. His lawyers are asking that we bill his insurance company first. This particular patient has xxxx insurance and the clearing house is rejecting the claim based on "ERROR 3430-Invalid principal diagnosis code." We lead with diagnosis code V43.52XA, could we change the position of the V43.52XA code? Or should we submit a paper claim for the case instead?

Answer:

The medical insurance company is rejecting the claim because they want a medical diagnosis. The advice would be the same as for all other cases, PI or not, you bill the appropriate injury and symptom codes for the encounter first (which is not an external cause - V code), and then follow it with applicable codes, like this one, which describe the encounter. In fact, since most payers do not require the use V codes, it is likely not required, but still helpful information to include.

According to Dr. Tom Grant, a personal injury claim expert, using V codes for PI cases is not important. In PI, neither the PI carrier nor the attorney care about the external cause codes. In fact, PI insurers already know details about crash events and what they need are the injuries and symptoms which will be outlined in the patient's medical record. They have their own internal method of tracking how crashes and injuries have occurred. Nevertheless, it does NOT hurt to have V codes, it's just not a priority.

As for the order of the diagnosis - the hierarchy for PI claims - it doesn't matter because their specialized software will determine the order of severity based on the entire claim. They do not rely on the order placed on a 1500 Claim Form.

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