Wiki G0296 Humana Primary Dx Z87.891

[awolf214]

Hello everyone,

Looking for guidance for one of my coders. We are billing G0296 CT Low Dose Lung Counseling to Humana Choice Medicare. We attached Dx: Z87.891 to this code. Humana has denied this code stating payment is not allowed for this service because the diagnosis billed is not valid as a primary diagnosis. The supervisor coder states this should be a good dx code. I submitted a reconsideration that was denied for the same thing. I contacted Humana and they were no help ofcourse . They could not provide any policy nor Article on CMS Gov that would help. Looking for guidance from other coders.

Other codes we are billing on this claim are: 99214, 96160, G0439, 99497, G0444, G0442, G0296
Dx's listed on claim but are not attached to G0296 are: R91.1, I10, E78.5, I25.10, K76.89, R73.9, C61, E66.9, Z00.00, Z13.31, Z13.39, Z78.9, J44.9
Modifiers attached to the claim : 25, 59, 33

I am not the coder on this claim just the Claims denial Representative.
I currently have my CPC-A but not currently in a coder job role.
Any help would be greatly appreciated.

Thank you

 

[TThivierge]

Hello everyone,

Looking for guidance for one of my coders. We are billing G0296 CT Low Dose Lung Counseling to Humana Choice Medicare. We attached Dx: Z87.891 to this code. Humana has denied this code stating payment is not allowed for this service because the diagnosis billed is not valid as a primary diagnosis. The supervisor coder states this should be a good dx code. I submitted a reconsideration that was denied for the same thing. I contacted Humana and they were no help ofcourse . They could not provide any policy nor Article on CMS Gov that would help. Looking for guidance from other coders.

Other codes we are billing on this claim are: 99214, 96160, G0439, 99497, G0444, G0442, G0296
Dx's listed on claim but are not attached to G0296 are: R91.1, I10, E78.5, I25.10, K76.89, R73.9, C61, E66.9, Z00.00, Z13.31, Z13.39, Z78.9, J44.9
Modifiers attached to the claim : 25, 59, 33

I am not the coder on this claim just the Claims denial Representative.
I currently have my CPC-A but not currently in a coder job role.
Any help would be greatly appreciated.

Thank you

AWolf
I suggest the coders READ the CPT manual and linking the proper dx to CPT codes is vital. Sequencing and modifier placement is important in coding. Sometimes the provider may list wrong CPT down, coder needs to fix it by reading documentation to ensure matches the CPT manual description. Ensure the Z dx codes are used properly....most Z dx codes should be last on claim NOT first. The ICD10 manual list Z dx codes which can be first vs secondary codes.The Z87.891 should be last (history of smoking).
It seems Humana is primary payer and should not be billed G0296(G codes only bill to Medicare as 2nd payer if have first payer). it seems the CPT 96160 is for health risk assessment. Did the provider do a assessment listed on treatment day's notations? If related to lung screening why not use respiratory J98 or R91 first until find out if Cancer results positive. If positive cancer test/lab then use C61 is Prostate Cancer not Lung Cancer? Did the patient have Cancer or not? Cancer ds. positive always bill first.The payer not pay cause all those conflicting dx and CPT codes..I hope not all on one claim for one day. If pt getting screening for lung cancer I d use J98.8 then dx R91 and Z13.31 and then Z87.891 if supported in notations.
Also was the provider doing 99214 and other services to justify modifier 25 to support the counseling all on one day? Also is this one visit or a few differ treatment dates by differ providers MD NP Psychiatrist or LCSW? Modifier 33 is usually done once a year as preventive measure.

Here is quick info tell coders....use Z dx codes properly, use modifiers properly, documentation from provider should match CPT code used, ensure aware type of visits is it new, Est, follow up, annual physical, injection or vaccines only, Etc. Maybe they need to create a cheat sheet per type medical service & payer type. I hope this data helps you and your coders.
Lady T

 

[sls314]

Humana Medicare should follow the same benefits that traditional Medicare would cover. I've provided some links below where you can research how traditional Medicare would cover LDCT.

CMS MLN for Medicare Preventive Services: see section on Lung Cancer Screening with Low Dose Computed Tomography (LDCT): https://www.cms.gov/medicare/preven...vices/mps-quickreferencechart-1.html#LUNG_CAN

NCD for Lung Cancer Screening with Low Dose Computed Tomography (LDCT): https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=364

The NCD also refers you to the Medicare Claims Processing Manual, which will give additional information on how Humana Medicare should process the claim: https://www.cms.gov/files/document/r11388cp.pdf

BTW - I noticed you mentioned R91.1 - if the patient already had a pulmonary nodule, that may be a problem for coverage of the LDCT. See the screenshot below from the MLN link. Medicare only covers the LDCT for patients who are asymptomatic (no lung cancer signs or symptoms).




Hope these links help with your research.

 

[CBLENNIE]

As someone who has worked for health insurance payers for 20+ years, including time spent in auditing and claims processing, I can say that seeing all of these procedure codes being billed on a single DOS during a single encounter would be seen as questionable. It would likely something I would report to our Special Investigation Unit (SIU) to review the claim and likely request records to ensure that the documentation support so many procedures billed during a single encounter on a single DOS.

How long was the patient's appointment for this encounter? You have a level 4 medical E&M being billed with 3 additional time-based codes, G0442, G0444 & 99497(which represents 30 minutes of time spent just on this service. Per the E&M Guidelines in the CPT manual "when using codes 99497, 99498, no active management of the problem(s) is undertaken during the time period reported." I want to acknowledge that 99214 is not limited to face-to-face time with the patient, but it is still questionable from a payer's perspective when you take into account the other procedures billed on a single DOS.