Excludes 1 denials - Preventive w/ Contraception Procedure on same day

[lmiller78]

Hello fellow coders! I am the sole coder at a Family Planning/Title X – State funded clinic. With that funding source we must adhere to guidelines set forth by the State in regards to women’s contraceptive measures. This means that if a woman presents for an annual exam and indicates that she wants a LARC (long acting reversible contraceptive) measure, then it is our mission to give her that LARC at the same visit. The charges would look like this:

CPT: 99395 -25 (Annual Exam) ICD-10: Z01.419 (Encounter for routine gynecological exam)
CPT: 58300 (IUD Insertion) ICD-10: Z30.430 (Encounter for insertion of IUD)
HCPCS: J7298 (Mirena IUD) ICD-10: Z30.430 (Encounter for insertion of IUD)

Most recently our local HMO has been denying the procedure and device codes and paying only the annual exam code. In doing more research, I have learned that the annual exam ICD-10 codes (Z00.00, Z01.419, Z01.411) have an Excludes 1 rule that does not allow an ICD-10 code for reproduction/contraception (Z30.011-Z30.49) to be billed on the same date of service as the annual ICD-10. In most offices the patient could be scheduled for the procedure at a later date, with our office this is not an option. If we bill only for the procedure we are leaving a lot of money on the table and vice versa.
I have checked CCI edits for proper CPT coding, and these codes should not bundle, I have billed them together for years without any denials, and have gone through audits for correct coding an no flags have been noted.
Any suggestions for a work around? I’ve exhausted my resources. Thank you in advance for your time and knowledge!

 

[mitchellde]

CPT rule and ICD-10 CM rules are not interchangeable. Just because CCI edits say you can bill procedures together does not mean that you have the diagnosis to support them given the diagnosis rules. Also the diagnosis codes go in field 21 of the physician claim, while the procedure go into filed 24. the field 21 edits will have priority, therefore the excludes 1 edit will adjudicate first. So no you cannot use both dx codes together and so cannot bill both procedures together.
There is an override to SOME of the excludes 1 edit effective until Oct 1 2016. You must be able to appeal that both conditions could exist at the same time and the edit was faulty. there are a few faulty excludes 1 edits. If you feel this one meets this criteria then you can try to appeal it.

 

[lmiller78]

Resolution

CPT rule and ICD-10 CM rules are not interchangeable. Just because CCI edits say you can bill procedures together does not mean that you have the diagnosis to support them given the diagnosis rules. Also the diagnosis codes go in field 21 of the physician claim, while the procedure go into filed 24. the field 21 edits will have priority, therefore the excludes 1 edit will adjudicate first. So no you cannot use both dx codes together and so cannot bill both procedures together.
There is an override to SOME of the excludes 1 edit effective until Oct 1 2016. You must be able to appeal that both conditions could exist at the same time and the edit was faulty. there are a few faulty excludes 1 edits. If you feel this one meets this criteria then you can try to appeal it.

Thank you Debra, for your response. I have since determined that the payer was denying in error. I have provided proof and the claims are set to pay. They were coded correctly, but their coder was using the Excludes 1 and Excludes 2 rules incorrectly.