Wiki Denial for Z12.11 code

We received a denial from BCBS for Missing/incomplete/invalid diagnosis or condition. The ICD 10 codes used are Z12.11, K57.30, and Q43.8. The CPT used is 45378. I’ve used these codes before and did not receive a denial. Do we just need to remove the K57.30 and Q43.8 codes?

Patdow
It seems like the K57.30 first dx , then dx Q43.8 and last dx Z12.11 or Z13.811 The coding sequence seems incorrect listed above. The ICD10 manual states dx Z12.11 is unacceptable as first dx code. Payers like details and specifics in DX and CPT coding which should match the documentation
I hope helped you
Lady T

If the reason for the colonoscopy was a screening, Z12.11 should be listed first. Z12.11 is an encounter for a screening colonoscopy, however, I would need to see the documentation to be sure Z12.11 is appropriate.

Listing the finding(s) following Z12.11 is correct.

I checked the ICD-10 manual, and Z12.11 is acceptable in the #1 spot, as there is no note stating otherwise.

TThivierge said:

Patdow
It seems like the K57.30 first dx , then dx Q43.8 and last dx Z12.11 or Z13.811 The coding sequence seems incorrect listed above. The ICD10 manual states dx Z12.11 is unacceptable as first dx code. Payers like details and specifics in DX and CPT coding which should match the documentation
I hope helped you
Lady T

Click to expand...

Again the ICD10 dx Z12.11 states in ICD10 manual it is NOT acceptable as principal first dx code. I do not make the rules but the payer may decide to follow the ICD10 manual in this case.
Lady T

Z12.11, is the encounter code for screening colonoscopy, so it is 100% acceptable as the first diagnosis. The ICD-10 manual does not states this at all regarding this code.

UPD appears next to diagnosis codes considered unacceptable primary diagnosis. Z12.11 does not have UPD next to it. It does have a QPP designation though.

patdow said:

We received a denial from BCBS for Missing/incomplete/invalid diagnosis or condition. The ICD 10 codes used are Z12.11, K57.30, and Q43.8. The CPT used is 45378. I’ve used these codes before and did not receive a denial. Do we just need to remove the K57.30 and Q43.8 codes?

Click to expand...

Wondering if you had any luck with this denial? We just got one from UCare Commercial Insurance for a Screening Colonoscopy in December: 45378 for Z12.11 and K57.30 with the reason: inconsistent diagnosis with procedure. Patient presented for a screening colonoscopy Diverticulosis found during scope, but asymptomatic.