General Surgery Coding Alert

Question: Our surgeon performed a colonoscopy for a patient with a personal history of colon polyps. The patient had a previous colonoscopy two years ago, which did not find colon polyps, nor did the current colonoscopy. We billed the procedure using Z86.010 and G0105. The patient’s primary insurance denied the claim because the “ICD-10 is an unacceptable principal diagnosis.” Please explain what we did wrong.

AAPC Forum Participant

Answer: The reason for the denial in this situation is that Z86.010 (Personal history of colonic polyps) cannot be the primary diagnosis code for G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). ICD-10-CM guideline I.C.21.4 tells you “the reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnose(s).”

In this case, you should select a code such as Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) for the first-listed code. Under that code, you’ll see a Use additional code instruction to add codes from Z86 (Personal history of certain other diseases) and Z87 (Personal history of other diseases and conditions). And to reinforce the guideline, both the Z86 and Z87 code groups carry the instruction to Code first any follow-up examination after treatment with Z09.