Aetna Coding Z5111 with J9033 is denying.

aervin

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HI,

Aetna denies our claims when we code Z5111 as primary reason for admission when billing J9033. It is my understanding per ICD-10-CM guidelines 2016. Section IV, Subsection L. Second paragraph: When the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z-code for this service is listed first, and the diagnosis or problem for which the service is being performed is second.

In this case secondary diag., C8221. However Aetna does pay when we bill other chemo drugs with (exp., J9310) with Z5111 as primary reason for admission.

Please note Aetna policy for J9033 does not list Z5111 as a qualifying diag., but I don't understand how I can get past this denial. Is it mandatory to code Z5111?
 
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You are correct about the sequencing. Out of curiosity, why are you using code C82.21 grade III unspecified? Is there a more specific code you can use? I'm wondering if they are looking for a specific code due to what that indications that drug has.
 
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