I received a denial from a commercial payer for an x-ray and E/M charge we billed stating that the diagnosis code is not a payable diagnosis. The patient was seen in the clinic as a one year follow up after having a total knee replacement. There were no complaints and no new problems, just simply checking that the prosthesis was properly fitted and no loosening was present.

I had billed the primary diagnosis of Z96.652 for presence of left knee prosthesis. I have billed this many times before and not received denials, however, now that I received a denial I need help finding a payable primary diagnosis for the visit. Since the patient has no new complaints and the problem of osteoarthritis has resolved, it wouldn’t be appropriate to use that code for the visit.

Does anyone have any ideas or suggestions on what I might be able to change without committing any kind of fraudulent billing? There really was no problem found so it was a simple follow up with x-ray.

Thank you!