Wiki Humana Denials 71271

Create Wiki Sort by votes
0
KELLEYB said:
Is anyone having an issue with Humana paying 71271 with ICD-10 Z87.891? We are billing professional only with a 26 modifier. We have been paid up until December and now claims are denying for DX code.
Click to expand...

Is this for commercial or Medicare? I only ask because I was looking up the Medicare coverage info to see if there were any recent changes, and it occurred to me that you might be talking about a commercial plan instead.

(We don't really have any commercial Humana in my area - it's pretty much all Medicare, so my instinct for Humana is always to jump right to looking up Medicare policies/LCD/NCD.)
 
Last edited:
0
sls314 said:
Is this for commercial or Medicare? I only ask because I was looking up the Medicare coverage info to see if there were any recent changes, and it occurred to me that you might be talking about a commercial plan instead.

(We don't really have any commercial Humana in my area - it's pretty much all Medicare, so my instinct for Humana is always to jump right to looking up Medicare policies/LCD/NCD.)
Click to expand...
This is for Medicare products.
 
0
There is an age restriction with Medicare: According to CMS, "71271 to be billed only if the beneficiary is between the ages of 50 and 77 for claims with date of service on or after February 10, 2022."
If the beneficiary is older than 77, how is this supposed to be billed out?
 
0
jalabergeron said:
There is an age restriction with Medicare: According to CMS, "71271 to be billed only if the beneficiary is between the ages of 50 and 77 for claims with date of service on or after February 10, 2022."
If the beneficiary is older than 77, how is this supposed to be billed out?
Click to expand...
It should never have been ordered and should neve have been performed. The provider failed to order according to guidelines, and the imaging facility failed to screen according to guidelines. Someone's eating the cost of the LDCT. Maybe the patient turned 78 after the physician ordered the LDCT. Unlikely, but possible. Even then, not certain Medicare would cover it.
 
0
sapenaatsmg said:
I submitted a code edit question to them and Humana is referencing this policy which states the Z87.891 cannot be in the primary position on the claim.

Click to expand...

Edit (5/23/2024): After reviewing it and giving it a lot more thought, I guess Medicare assumes the coder will code Z12.2 as the primary diagnosis since 71271 is a screening, and so, the six codes it specifies in the IOM, Medicare must assume the coder understands those to be used for the secondary diagnosis, in accordance with ICD guidelines (below, p. G31 of 2024 AAPC ICD-10-CM Expert).

coding screening with abnormal finding.png

I guess 71271 is just kind of unusual because normally we don’t have have additional diagnoses to code until after the screening is performed, but in this case, we code them before the screening is performed. However, then I think of a “surveillance” colonoscopy where we would code Z12.11 and then whatever additional diagnosis for which the “surveillance” colonoscopy is warranted (e.g., Z86.010), and yet even today, the “surveillance” colonoscopy is such a gray area. Even mammography has no such thing as a surveillance mammogram. It’s either [asymptomatic] screening, or if abnormal, it is diagnostic for 3 years and then if those mammograms are all normal, then resume screening mammograms.

In any case, I will start using Z12.2 as the primary and then one of the six as secondary. There seems to be a basis for it per the ICD-10 guidelines.


What exactly is Humana referencing in the ICD-10 guidelines that states “the Z87.891 cannot be in the primary position on the claim”?

Per Medicare Claims Processing Manual (100-04), Chapter 18,

220 - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (Rev. 3374, Issued: 10-15-15, Effective: 02-05-15, Implementation: 01-04-16)

220.4 – Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages (Rev11388, Issued:04-29, 22; (Effective:02-10-22; Implementation:10-03-22)

“Denying claim lines for HCPCS G0296 and 71271 because the claim line was not billed with ICD-10 codes Z87.891 (personal history of tobacco use/personal history of nicotine dependence), F17.210 (Nicotine dependence, cigarettes, uncomplicated ), F17.211 (Nicotine dependence, cigarettes, in remission), F17.213 (Nicotine dependence, cigarettes, with withdrawal), F17.218 (Nicotine dependence, cigarettes, with other nicotine-induced disorders), or F17.219 (Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders), effective with dates of service on or after October 1, 2015.“

What that paragraph states is that Medicare will deny a claim for 71271 (the LDCT for lung cancer screening) if the claim does not have one of those specified ICD-10 codes: Z87.891, F17.210, F17.211, F17.213, F17.218, or F17.219. Notice that the paragraph makes no mention whatsoever of Z12.2 Encounter for screening for malignant neoplasm of respiratory organs. If one of those six ICD-10 codes is not listed as the on the claim for the 71271, Medicare will deny the claim. Those are the only six ICD-10 codes Medicare seems to be concerned with for 71271.

Hence, American College of Radiology states the following,[1]

Medicare will deny G0296 and 71271 for claims that do not contain these ICD-10 diagnosis codes:
  • Z87.891 for former smokers (personal history of nicotine dependence).
  • F17.21 - for current smokers (nicotine dependence).
    • F17.211 Nicotine dependence, cigarettes, in remission
    • F17.213 Nicotine dependence, cigarettes, with withdrawal
    • F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders
    • F17.219 Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders
Click to expand...
 
Last edited:
You must log in or register to reply here.
Top