Wiki screening colonoscopy: correct coding of primary and subsequent diagnoses

[sonnyosty]

A patient scheduled a screening colonoscopy, confirmed by ins rep to be covered benefit at 100%. Based on a past history (over 10 yrs.) of benign colonic polyp, procedure was coded with Z86.010 (personal hx benign colonic polyp) as primary and sole diagnosis. I understand correct coding rationale to be: primary dx - Z12.11/screening colonoscopy, and secondary dx - Z86.010, due to polyps not being an active illness/condition and, further, because no polyps were found on colonoscopy. However someone told me that even if "screening" diagnosis Z12.11 is submitted as primary, if a "history of" diagnosis (i.e. Z86.010) is sequenced 2nd, 3rd, etc., the claim won't be processed as a 100% coverage benefit, unless patient has Medicare, since as of 2012, although pre-existing diagnoses (i.e. "hx of") are "covered" under the Affordable Care Act, the caveat is that if they are now life-time factors and if included anywhere in the diagnosis sequencing, even if in the extreme past/not currently active or concerning, and even with "screening" dx as primary, commercial payers assign the responsibility to patient's out-of-pocket. Can anyone clarify and/or validate this?

 

[01065679]

screening colonoscopies

A patient scheduled a screening colonoscopy, confirmed by ins rep to be covered benefit at 100%. Based on a past history (over 10 yrs.) of benign colonic polyp, procedure was coded with Z86.010 (personal hx benign colonic polyp) as primary and sole diagnosis. I understand correct coding rationale to be: primary dx - Z12.11/screening colonoscopy, and secondary dx - Z86.010, due to polyps not being an active illness/condition and, further, because no polyps were found on colonoscopy. However someone told me that even if "screening" diagnosis Z12.11 is submitted as primary, if a "history of" diagnosis (i.e. Z86.010) is sequenced 2nd, 3rd, etc., the claim won't be processed as a 100% coverage benefit, unless patient has Medicare, since as of 2012, although pre-existing diagnoses (i.e. "hx of") are "covered" under the Affordable Care Act, the caveat is that if they are now life-time factors and if included anywhere in the diagnosis sequencing, even if in the extreme past/not currently active or concerning, and even with "screening" dx as primary, commercial payers assign the responsibility to patient's out-of-pocket. Can anyone clarify and/or validate this?

When was the patients last colonoscopy? If the procedure has been over ten years then all insurance companies should pay 100%. Medicare allows for high-risk screenings and will acccept personal history of or family history of codes; however insurances like Oxford or Oscar will not pay for a screening unless they see the Z12.11. (But alot of that also depends on the plan the patient has not just the insurance itself)
If the patient has had frenquent colonoscopies (such as every 2 years, because of HX of ployps) a lot will depend on how the past procedures were coded. If the last was coded with just the Z12.11 and no issues, the insurance will not accept anotherone for 10 years because on paper they are not eligable, even Medicare. If the past ones were coded as high-risk, then then there shouldnt be a problem for most insurances.

Lastly, if during the procedure biospys were done, the screening would need to be coded with a modifier to show it started off as a screening and turned diagnostic. PT if Medicare or 33 for commerical payors.

Hope this helps

 

[sonnyosty]

screening colonoscopies w/pers hx coloniic polyp over ten years ago

Thank you for the reply. It was helpful but there are further questions needing clarification please. Patient's last screening colonoscopy was 6 years ago (2011), w/no abnormal findings. There was a benign colonic polyp on colonoscopy done more than 10 years ago (2006). Screenings were recommended every 5 years by pt's previous carrier (HMO) and by the current payer, one of the bigger commercial insurance companies. It is not known whether the last colonoscopy (performed with patient's previous insurance) was coded with a diagnosis other than the routine screening diagnosis, but it was covered at 100%, under the screening benefit. In coding the patient's recent colonoscopy, the doctor did not include Z12.11/screening diagnosis at all but, rather, coded Z86.010/personal history benign colonic polyp. Since pt's chief reason for this visit was "routine screening," I find correct coding guidelines which support Z12.11 for "screening" to be listed as Primary, followed by Z86.010/personal history benign colonic polyp. The rationale in ICD-10 proficiency training also supports what I believe to be correct, i.e. screening is testing for disease in seemingly well individuals for early detection and that if a condition is discovered during screening, then a code for that condition would be assigned as an additional diagnosis. Further, that if the condition is not active or concerning (which it wasn't, no biopsies were done, as no polyps were found on this one, i.e. it did not turn diagnostic), then it is not correct to code a personal history diagnosis code as the Primary diagnosis, although it can be properly listed as a subsequent diagnosis.
1.) I am suggesting the doctor must include Z12.11/screening as Primary, with Z86.010 sequenced Secondary, as proper coding. Please correct me if this is not so, and supporting rationale would be very much appreciated.
2.) I have not been directly involved in the reimbursement side lately but in my experience, whether Z12.11 was the Primary and sole diagnosis. or whether Z12.11 was Primary with Z86.010 as Secondary, I had not encountered any difference in how commercial payers processed screening colonoscopies toward their members' 100% screening-coverage benefit. Has this changed? Realizing that Medicare allows for high-risk screening and accepts personal and/or family history codes when they are subsequent to the screening code, for commercial payers, if a diagnosis other than screening is included (even when Z12.11 is primary), are they declining to recognize it as a "screening" under their members' screening benefit?
3.) As of 2012, did the Affordable Care Act change how commercial payers process screening colonoscopies, so that they are now only allowing Z12.11 to be billed every 10 years in order to be covered at 100% under their member's screening benefit plan?
Thank you.