Primary diagnosis for colonoscopy

cherylbr

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We have recently been advised by a carrier in Arizona (Medicaid) that the diagnosis code Z12.11 cannot be billed as the primary diagnosis. They stated that this goes for CMS or any other insurance carrier. They are stating that if they pay it on their end, then it is going against the guidelines that CMS has set forth. They are telling us if we have anything that contradicts this statement please forward it to them.

I am not aware of this guideline. We submit to other carriers using the Z12.11 as primary and don't have any issues with payment. Can anyone direct me or provide information regarding this?

Anyone submitting anesthesia claims for colonoscopies can you tell me what position are you placing the Z12.11 diagnosis in when it is applicable?
 
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Which ASA code are you using and which Medicaid payer is it? State Medicaid or a contractor like Mercy Care?
 

cherylbr

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Sheryl,

The carrier is Arizona Complete Health. I believe this is Arizona's State Medicaid Plan.

I did note in the 2019 ICD -10 book where is does give a symbol behind the code Z12.11 that indicated "unacceptable principal diagnosis symbol per Medicare code edits". This present a problem when the patient is truly having a screening colonoscopy (00812) and there is no other purpose but for this. What other primary diagnosis could we possibly use?

Thanks!
 

mitchellde

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when the code book designates a code as unacceptable principle diagnosis this is not the same as a first listed diagnosis code. Principle diagnosis is a facility term not a profee term. SO when a code is designated in the code set as unacceptable principle dx that means for inpatient admission. Z12.11 is an acceptable first-listed code for a pro-fee claim. Perhaps you are using the wrong procedure code. Many payers prefer the G code for a screening colonoscopy, if you are not using the G code then you may need a modifier PT for Medicare or 33 for other payers to indicate a CPT code that is not preventive by description , but being performed for preventive reasons.
 
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I will say this about Arizona Complete Health...they have been a thorn in our side for the past year or so (anesthesia) because they can't process our claims correctly to save their lives. They mess up the labor epidurals, they mess up minutes with base units. They were denying erroneously for different things.

If the claim was truly just a timely screening with no findings, then 00812 with Z12.11 is absolutely correct. AZCH is in error.

Sheryl

Sheryl,

The carrier is Arizona Complete Health. I believe this is Arizona's State Medicaid Plan.

I did note in the 2019 ICD -10 book where is does give a symbol behind the code Z12.11 that indicated "unacceptable principal diagnosis symbol per Medicare code edits". This present a problem when the patient is truly having a screening colonoscopy (00812) and there is no other purpose but for this. What other primary diagnosis could we possibly use?

Thanks!
 

LisaAlonso23

Expert
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They must have a glitch in their system. Screening colonoscopies are coded as follows:

Screening with nothing else done:
45378/00812
Z12.11, Finding, Co-morbidity diagnosis to justify anesthesia if provided

Screening with polypectomy (polyp found in cecum, for example):
45380/00811-PT
Z12.11, D12.0, Co-morbidity diagnosis to justify anesthesia if provided

Screening colonoscopy with EGD:
45378/00813
Z12.11, Finding, DX for EGD, Co-morbidity diagnosis to justify anesthesia if provided

Without Z12.11, the procedure will not be considered a preventive screening resulting in the the patient being charged.

In the 2019 ICD-10 manual, the symbol next to Z12.11 (Q) means QPP condition that indicates the condition is recognized as a quality measure for MIPS reporting.
 

cherylbr

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Sheryl,

I can't thank you enough for your assistance in this mess! My next step is to provide proof to AZCH that what they are stating is inaccurate. Where do I locate the information you provided about "when the code book designates a code as unacceptable principle diagnosis this is not the same as a first listed diagnosis code. Principle diagnosis is a facility term not a profee term. SO when a code is designated in the code set as unacceptable principle dx that means for inpatient admission. Z12.11 is an acceptable first-listed code for a pro-fee claim"?
They are telling us if we have anything that contradicts their statement that we can forward it to them. They stated that "their system is set up that claims with this diagnosis as primary would deny and cannot be overridden by the claims department due to it being an HCI edit." In order to get this overridden we need to submit a reconsideration or appeal that must be reviewed by the HCI team and/or medical management!

Thank you so very much again for your help!
Cheryl B.
 

cherylbr

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I can't thank you enough for your assistance in this mess! My next step is to provide proof to AZCH that what they are stating is inaccurate. Where do I locate the information you provided about "when the code book designates a code as unacceptable principle diagnosis this is not the same as a first listed diagnosis code. Principle diagnosis is a facility term not a profee term. SO when a code is designated in the code set as unacceptable principle dx that means for inpatient admission. Z12.11 is an acceptable first-listed code for a pro-fee claim"?
They are telling us if we have anything that contradicts their statement that we can forward it to them. They stated that "their system is set up that claims with this diagnosis as primary would deny and cannot be overridden by the claims department due to it being an HCI edit." In order to get this overridden we need to submit a reconsideration or appeal that must be reviewed by the HCI team and/or medical management!

Thank you so very much again for your help!
Cheryl B.
 
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I would first ask you what place of service are you billing? If you are billing 21 for inpatient, then that is the problem.

Second, did you have the claims representative send the claim back for review by a supervisor explaining that Z12.11 can be the primary diagnosis for a physician claim? We have sent claims back for review, sent in "reconsiderations" etc before doing an actual dispute/appeal.




I can't thank you enough for your assistance in this mess! My next step is to provide proof to AZCH that what they are stating is inaccurate. Where do I locate the information you provided about "when the code book designates a code as unacceptable principle diagnosis this is not the same as a first listed diagnosis code. Principle diagnosis is a facility term not a profee term. SO when a code is designated in the code set as unacceptable principle dx that means for inpatient admission. Z12.11 is an acceptable first-listed code for a pro-fee claim"?
They are telling us if we have anything that contradicts their statement that we can forward it to them. They stated that "their system is set up that claims with this diagnosis as primary would deny and cannot be overridden by the claims department due to it being an HCI edit." In order to get this overridden we need to submit a reconsideration or appeal that must be reviewed by the HCI team and/or medical management!

Thank you so very much again for your help!
Cheryl B.
 
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