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araceli.tinta@gmail.com

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I am confused about a denial we received. The patient was seen for knee pain and requested a mammogram. We billed CPT code 99214, but the provider ordered labs and used the diagnosis code Z01.411. The insurance company states that this diagnosis should only be used as a primary or sole diagnosis. However, if we bill it as the primary diagnosis, we need to use a preventative CPT code. The patient was not seen for a preventative visit. What should I do?
 
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trarut said:
Why did your provider order the labs? Based on your post, I don't see the correlation between knee pain and labs for a gyn exam with abnormal results. I think we're missing part of the story ;)
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This is the Assessment/ Plan
Assessment/Plan
1.Assessment
Breast cancer screening by mammogram (Z12.31).
Plan Orders
SCR MAMMO BI INC CAD W/3D Tomosyntesis to be performed. on Bilateral.

2.Assessment
Pain in left knee (M25.562).
Patient Plan
-Patellar sensitivity upon movement., bilaterally.
Plan Orders
Active Medication: diclofenac 1 % topical gel

3.Assessment
Pain in right knee (M25.561).
Plan Orders
Physical Therapy.

4.Assessment
Encounter for well woman exam with abnormal findings (Z01.411).
Plan Orders
CBC (INCLUDES DIFF/PLT) to be performed, COMPREHENSIVE METABOLIC PANEL to be performed, HEMOGLOBIN A1C WITH MPG to be performed, LIPID PANEL WITH REFLEX TO DIRECT LDL to be performed, TSH W/REFLEX TO FREE T4 to be performed, VITAMIN B12/FOLATE, SERUM PANEL to be performed and VITAMIN D 1,25-DIHYDROXY, LC/MS/MS to be performed.
 
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araceli.tinta@gmail.com said:
This is the Assessment/ Plan
Assessment/Plan
1.Assessment
Breast cancer screening by mammogram (Z12.31).
Plan Orders
SCR MAMMO BI INC CAD W/3D Tomosyntesis to be performed. on Bilateral.

2.Assessment
Pain in left knee (M25.562).
Patient Plan
-Patellar sensitivity upon movement., bilaterally.
Plan Orders
Active Medication: diclofenac 1 % topical gel

3.Assessment
Pain in right knee (M25.561).
Plan Orders
Physical Therapy.

4.Assessment
Encounter for well woman exam with abnormal findings (Z01.411).
Plan Orders
CBC (INCLUDES DIFF/PLT) to be performed, COMPREHENSIVE METABOLIC PANEL to be performed, HEMOGLOBIN A1C WITH MPG to be performed, LIPID PANEL WITH REFLEX TO DIRECT LDL to be performed, TSH W/REFLEX TO FREE T4 to be performed, VITAMIN B12/FOLATE, SERUM PANEL to be performed and VITAMIN D 1,25-DIHYDROXY, LC/MS/MS to be performed.
Click to expand...


Z01.411 is Encounter for gynecological examination with abnormal findings. That code also has a note to Use additional code to identify abnormal findings

Did your provider perform a pelvic exam and document abnormal findings that you didn't share above? If not, it's not appropriate to use that diagnosis on the claim.

(If all they did was order some basic routine labs, I'm not sure why they chose a gynecological exam code for it anyhow?)

Furthermore, the Z12.31 Encounter for screening mammogram for malignant neoplasm of breast is not appropriate for the claim either.

The provider referred the patient to another provider for a mammogram; the provider did not perform the mammogram at this visit.
 
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