Wiki Z96.1 w/ H59.811

[TMacFarlane]

is this correct ? our 2023 ICD10 books clearly states that Z96.1 is excludes 1 to H59.811 and should not be billed together, but our administrator is using some other resource and is pulling some kind of exception rule that is not stated in ICD10 texts.

Any advice or comments are appreciated

 

[sls314]

is this correct ? our 2023 ICD10 books clearly states that Z96.1 is excludes 1 to H59.811 and should not be billed together, but our administrator is using some other resource and is pulling some kind of exception rule that is not stated in ICD10 texts.

Any advice or comments are appreciated


View attachment 6659

Well, first of all, your administrator is wrong in thinking it is a "Humana issue." She should be aware that payers are getting more savvy with coding guidelines and Excludes notes. Many payers are implementing more and more code edits by the month.

Just because it slipped through in the past with UHC doesn't mean that the coding was correct even then. It doesn't even mean that UHC would pay the same claim the same way if the same claim was billed today.

"It worked before" is never a reason to not follow proper coding guidelines.

That being said...is the intraocular lens in the right eye or the left eye?

Since the H59.811 is for the right eye, if the intraocular lens is in the left eye, that could be justification to the payer that the conditions are unrelated. If your administrator thinks that it's worth the time to appeal with documentation, I guess that's her choice.

If both codes are for the right eye though, you'd be wasting your time arguing it with the payer (in my opinion). Unless there's some absolute reason to keep the Z96.1 on the claim, I personally would remove the diagnosis code and be done with it.

 

[sls314]

"Supercoder" is a blast from the past though. It's been at least a few years since TCI Supercoder became Codify.