Wiki Appropriate dx z-codes to use with I10 and E11.9 for office visits to avoid denials

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she803

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Good evening all.
Billing department for outpatient hospital E/M visits have been receiving denials due to providers only billing I10 hypertension or E11.9 diabetes, etc.

However, when reviewing medical reports, either providers would document follow up based on these patients' conditions in addition to medications and lab results for the patient conditions.

Can an experienced coder/auditor provide me with the appropriate z-codes and sequence order to use for these cases in order to be reimbursed?


Thank you for your assistance!
 
In many years of coding and billing I have never heard of such a denial - are you able to give a little more information about what exactly the payer is stating in the reason for the denial? You can only code what is documented in the record and can’t add codes that aren’t supported just because of a denial. These conditions are valid and do require management and treatment and I can’t imagine that a payer would deny these because they want more codes - that just doesn’t make sense. There must be more to this than what you’re being told here.
 
Hi She803
Maybe the payers might want more detail if pt has combo illness with HTN 110 or DM E11.9. The documentation of course should match the dx code. But are chronic conditions added if supported? There are like differ stages of HTN 110, 111, 115 if warranted. . Also E11 DM has differ levels and comb codes if appropriate .There are factors need to be mentioned if patient has ongoing DM problems with neuropathy, kidney,opthamology, obesity, Etc. If billing wrong Z dx code first it might deny or hardly pay anything at all. There are certain types of Z dx codes which can be primary Z01, Z03, Z51 blocks as examples. The other last digit Z code might help are Z51.81 monitoring meds, or dx Z76 if given prescriptions but put lastly on claim. Is the provider just using unspecified dx codes? Or is the patient being seen by more than one provider at differ location for same dx problems of E11.9 and II0 dx? I know if patient suffers with DM E11.9 and has Medicare funding requires 82962 lab it done in office 2 times a year. I do not know if these patient are under Medicare coverage you are referring too. I know Medicare patients must get a physical every year or not cover services. May be this is another reason for the denial ...more preventive care on routine schedule. I am just trying to guess but from my past experience of working denials this has happened. Or maybe the documentation is not up to snuff in the payer s view for these patients why refusing to pay. You might want to call or view payer policy.
I am just adding suggestion to help.
Lady T
 
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Here's a thought: We are instructed to use a Z79 diagnosis code to show how the diabetes is controlled eg Z79.4 insulin, Z79.84 oral hypoglycemic, Z79.85 injectable non-insulin antidiabetic. Would reporting from this code series help to show medical necessity?
 
Hi Ens555
No if reports these dx code first on claim as dx Z79.84, Z79.85, Z79.4. does not show medically necessity. If that is only dx codes used to bill payer probable deny the claim. If the pt has definitive dx for Diabetes M. use one of the dx blocks of E11.9 first on claim reflecting pt problem. Also if pt. get insulin and pills for management dx E11 you should not bill both. I read just bill Z79.4 if long term use of insulin if pt gets both pills & insulin.
I hope this data helps you
Lady T
 
Thank you all for your replies--I greatly appreciate it!
An example: one of the patient records would indicate reason for visit "followup" and chief complaint documents as as "hypertension" dx I10.

These are general medicine providers billing dx I10 alone with no other dx codes; although the patient chart also includes medication management list for name of drugs, dosage, etc for hypertension.

However, the denials we would receive would state "invalid dx I10" due to billing dx I10 alone does not support medical necessity for office visits.

Therefore, my question is which Z-codes would I apply to I10 hypertension to support medical necessity when there are no other dx's on the patient report, but only the medication management as stated in previous paragraph?

Same question applies to E11.9 denials as invalid dx when it's the only dx code that was billed due to not supporting medical necessity. What other Z-codes can I apply to E11.9 to support medical necessity? Same denials apply when dx E78.5 for hyperlipidemia billed alone or E03.9 for hyperthyroidism.

We are receiving tons of these denials.

Thanks again everyone--truly appreciate your time, patience and assistance! 😊😊
 
TThivierge said:
Hi She803
Maybe the payers might want more detail if pt has combo illness with HTN 110 or DM E11.9. The documentation of course should match the dx code. But are chronic conditions added if supported? There are like differ stages of HTN 110, 111, 115 if warranted. . Also E11 DM has differ levels and comb codes if appropriate .There are factors need to be mentioned if patient has ongoing DM problems with neuropathy, kidney,opthamology, obesity, Etc. If billing wrong Z dx code first it might deny or hardly pay anything at all. There are certain types of Z dx codes which can be primary Z01, Z03, Z51 blocks as examples. The other last digit Z code might help are Z51.81 monitoring meds, or dx Z76 if given prescriptions but put lastly on claim. Is the provider just using unspecified dx codes? Or is the patient being seen by more than one provider at differ location for same dx problems of E11.9 and II0 dx? I know if patient suffers with DM E11.9 and has Medicare funding requires 82962 lab it done in office 2 times a year. I do not know if these patient are under Medicare coverage you are referring too. I know Medicare patients must get a physical every year or not cover services. May be this is another reason for the denial ...more preventive care on routine schedule. I am just trying to guess but from my past experience of working denials this has happened. Or maybe the documentation is not up to snuff in the payer s view for these patients why refusing to pay. You might want to call or view payer policy.
I am just adding suggestion to help.
Lady T
Click to expand...
Thank you, Lady T! Appreciate your assistance! :)
My question is which of the following subcategories from the Z-codes you provided (Z01, Z03, Z51) would apply?

And as for dx Z76.0--description indicates "encounter for issue of repeat prescription"--again I'm a little baffled about this code because in this case there is no issue when the patient reports indicate they are only receiving Rx refill from the provider for the above conditions mentioned.

I've also read that dx Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) can be coded as primary, but the description indicates after completed treatment. I find this description a bit confusing--not sure if it applies to this case since patient's treatment has not been completed. Please advise :)
 
Can you clarify if this is one particular payer or is this across the board? I've never heard of this type of denial and hypertension is definitely sufficient to justify medical necessity for AN office visit, but perhaps not the LEVEL of office visit billed or the type of visit billed.
 
she803 said:
Thank you all for your replies--I greatly appreciate it!
An example: one of the patient records would indicate reason for visit "followup" and chief complaint documents as as "hypertension" dx I10.

These are general medicine providers billing dx I10 alone with no other dx codes; although the patient chart also includes medication management list for name of drugs, dosage, etc for hypertension.

However, the denials we would receive would state "invalid dx I10" due to billing dx I10 alone does not support medical necessity for office visits.

Therefore, my question is which Z-codes would I apply to I10 hypertension to support medical necessity when there are no other dx's on the patient report, but only the medication management as stated in previous paragraph?

Same question applies to E11.9 denials as invalid dx when it's the only dx code that was billed due to not supporting medical necessity. What other Z-codes can I apply to E11.9 to support medical necessity? Same denials apply when dx E78.5 for hyperlipidemia billed alone or E03.9 for hyperthyroidism.

We are receiving tons of these denials.

Thanks again everyone--truly appreciate your time, patience and assistance! 😊😊
Click to expand...
I'd just reiterate what I said above that these denials make no sense. Diabetes or hypertension don't support medical necessity for an office visit??? According to whom? That's completely absurd, and this sounds like a gross error on the part of the payer.

Has anyone spoken to the payer about these denials or identified what particular guidelines the payer may have in place that require some additional diagnosis codes for certain types of visits? Do you really know for a fact that the payer is looking for Z codes in these situations and that this will resolve the problem? If you're not sure that this will take care of it, I'd strongly recommend against just trying things to see if they fix the denials as you could just end up compounding the problem further and/or wasting a lot of time and resources. Z codes don't normally support medical necessity - these codes are for additional information. And as I mentioned before, you can't just add codes if the information to support them isn't in the record. If there's a medical necessity issue going on here, then the payer must have a published policy out there that clearly explains these denials and what their expectations are from the providers. If they don't have such a policy, then what you're seeing is likely a payer error or claims system programming problem that needs to be corrected.
 
trarut said:
Can you clarify if this is one particular payer or is this across the board? I've never heard of this type of denial and hypertension is definitely sufficient to justify medical necessity for AN office visit, but perhaps not the LEVEL of office visit billed or the type of visit billed.
Click to expand...
I would not say it is across the board, but there are multiple payers. I cannot remember them all, but one of them I believe are AmeriChoice or AmeriHealth. I work outpatient and inpatient for a trauma hospital. These cases are outpatient o/v.
 
she803 said:
I would not say it is across the board, but there are multiple payers. I cannot remember them all, but one of them I believe are AmeriChoice or AmeriHealth. I work outpatient and inpatient for a trauma hospital. These cases are outpatient o/v.
Click to expand...
Now I really think this has more to do with the type of visit, POS or something else on the claim than with the actual diagnosis. The diagnosis may be the trigger but it is not the root cause of the denial. Contact the plan or work with someone at your employer who can. Ask the plan for the policy number they are using to make this determination. Have them fax it to you if needed.
 
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