# Z12.11 vs. Z86.010



## missyah20 (Apr 13, 2016)

Good Morning All - 

This may have already been covered but I have a question.  We had a patient who presented for a 5 yr. follow up due to a personal history of colon polyps.  This is the stated diagnosis on the operative report.

The facility billed Z12.11 and then Z86.010 per the AHA Coding Clinic Fourth Quarter 2013: "Assign code V76.51, special screening for mal neoplasms, colon, as the first-listed diagnosis for the surveillance colonoscopy.  Code V12.72 should be assigned as an additional diagnosis.  A surveillance colonoscopy is still a screening, and patients are being screened for malignancy; however it is considered a high-risk screening exam due to the history of previous polyps."

This patient has UMR United HealthCare as their insurer and per the UHC Guidelines CDG-A-036: "A patient had a polyp found and removed at a prior preventative screening colonoscopy.  All future colonoscopies are considered diagnostic because the time intervals between future colonoscopies would be shortened."  

Our office billed with Z86.010 as primary which of course meant this was processed toward the patient deductible.  My question is which is the correct way.  Do you follow the insurance guidelines or the AHA guidelines?

Thanks!


----------



## mitchellde (Apr 13, 2016)

I have always followed coding clinics.  They are considered by all authorities to be the last word in coding compliance.


----------



## missyah20 (Apr 13, 2016)

Thanks for your quick response!!  It is much appreciated.


----------



## valleycoder (Apr 13, 2016)

I would code according to the payer in that case.


----------



## pamsbill (Apr 16, 2016)

You cannot use the screening code with United, Aetna or Cigna. They all have stated prior polyps escalate the screening timeframe (no longer every 10 years) therefore they do not consider a patient with previous polyps to be a screening colonoscopy.


----------

