Wiki Z03.89 and diabetes

[Stenglein]

Diabetic exams and the "normal" oct (no retinopathy). E10.9 and E11.9 are not payable for the OCT, and clinicians feel they should be paid for the oct and want to use Z03.89. I am looking for documentation to either support or deny the use of the Z03.89 coding. Diabetes is a disease and I feel the oct should be coded to the correct code whether payable or not. Not finding good guidelines in wps. Anyone have anything they can share??

 

[thomas7331]

I agree with you - in my opinion, Z03.89 would be incorrect coding. Per ICD-10 guidelines, this code "is to be used when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is ruled out." If the documentation shows that the patient is diabetic and that the diabetes is a factor in the reason the test is being done, then this is not a patient without signs or symptoms and Z03.89 is not correct.

If this is not covered for a diabetic patient, I imagine that coding Z03.89 would probably not help to get it paid anyway - it's unlikely that a payer would offer this as a benefit to an asymptomatic patient but deny it to a diabetic patient. I would recommend you reach out to your payer for their coverage guidelines for this service and see what are their criteria for reimbursement - it may simply not be covered for certain patients. Or, they may provide some specific instructions on how they expect it to be coded for payment if the patients meet their criteria.

 

[saddie2k]

I agree, the code is incorrect. Check payer policy but the E10.9 and E11.9 are usually not covered because while they are diabetic, there is no ocular manifestation therefore no reason to perform the test. It would be the same as saying a patient was seen with Z01.00 exam without abnormal findings but wanting to bill for an OCT. Performing the test to reaffirm no retinopathy as seen on exam would be for Drs documentation purposes only.

 

[Stenglein]

Thank you so much!!

 

[Cheezum51]

My 2 cents as a provider. Assuming you have done the dilated fundus exam and found no sign of diabetic retinopathy, thus your E10.9 or E11.9 code, there is no justification for doing an OCT scan. Thus, it's not going to be paid for.

IMHO, you shouldn't be looking for ways to be paid for a procedure/test which wasn't necessary to begin with. The OCT should only be ordered if there are signs of diabetic retinopathy from the fundus exam to help determine if the DR is affecting the macular area.

Tom Cheezum, OD, CPC, COPC