Wiki Coding for BRCA+

[jlcheritage]

I am hoping that someone can help me with this. I have an account that is being denied payment because Aetna is stating that the patient bill for reconstructive surgery of the breast cannot be paid because of genetic changes /sex change on the patient. I called the physician and there was no gender change on this patient. the patient has had her uterus, ovaries and breasts removed becuase she was BRCA+.

I coded the Z15.01 dx in the last position on the claim. should it be in the first position. what do we do to make Aetna understand that this patient did not undergo a gender change.

 

[Nreed]

I am hoping that someone can help me with this. I have an account that is being denied payment because Aetna is stating that the patient bill for reconstructive surgery of the breast cannot be paid because of genetic changes /sex change on the patient. I called the physician and there was no gender change on this patient. the patient has had her uterus, ovaries and breasts removed becuase she was BRCA+.

I coded the Z15.01 dx in the last position on the claim. should it be in the first position. what do we do to make Aetna understand that this patient did not undergo a gender change.

Per Chapter 21 guidelines in the ICD-10 book, codes from the Z15 category should not be used as principal or first listed codes. If the patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition should be sequenced..... I would suggest looking for their policy on these types of procedures with this diagnosis to see if they cover them at all, or consider them experimental because their effectiveness hasn't been proven.

 

[thomas7331]

I think ICD-10 code Z42.1 - Encounter for breast reconstruction following mastectomy - would be a more appropriate code for this. The reconstruction is not done due to the genetic susceptibility - it is done because of the prior mastectomy. But you may need to review Aetna policies to find out what their coverage and payment criteria are for the specific procedure.

 

[jlcheritage]

thanks for the help. i just circled back to these and saw them. thanks again

 

[bunniebell]

I am hoping that someone can help me with this. I have an account that is being denied payment because Aetna is stating that the patient bill for reconstructive surgery of the breast cannot be paid because of genetic changes /sex change on the patient. I called the physician and there was no gender change on this patient. the patient has had her uterus, ovaries and breasts removed becuase she was BRCA+.

I coded the Z15.01 dx in the last position on the claim. should it be in the first position. what do we do to make Aetna understand that this patient did not undergo a gender change.

10-12-2020
Read the guideline under Z15 for Genectic Susceptibility. You may need to send copy to Aetna with the claim. Last ask for Aetna's policy on billing for the Reconstructive Breast Surgery. There may specific criteria that has to be followed.

Bunnie