Wiki Pre-op Z-code question

pookergirl

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Lab order diagnoses codes are Z01.818 and M16.11 - only labs were charged and our guidelines are to change the Z01.818 to Z01.812 in this situation; however, when I do that, the Hgb fails medical necessity. What would you do in this scenario?

Thanks.
 
Medical necessity edits are based on payer reimbursement policies (usually Medicare LCDs) so you would need to take a look at your particular payer’s published policies to see whether or not the edit is accurate and if test is covered with Z01.812. Or it may be that the payer requires Z01.818 to be billed for pre-operative lab tests, in which case your organization may need to look at updating your own guidelines for changing the codes so that you are correctly aligned with your payer requirements.
 
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