Oncology & Hematology Coding Alert
Check This Principal Dx Guideline for Chemo Denial
Question: Blue Cross Blue Shield (BCBS) of Illinois is denying 96402 when billed for C61, prostate cancer. The denial states “missing/invalid diagnosis or condition.” They are paying J9217 for the drug, but not 96402 and they have the same diagnosis code. I have been unable to locate any policy to explain this. Do you know why they are denying prostate cancer treatment for prostate cancer? AAPC Forum Participant Answer: In this situation, the denial doesn’t align. However BCBS is likely following ICD-10-CM coding guidelines to the letter, particularly guideline I.C.21.c.16, which provides a list of encounter (Z) codes that “may only be reported as the principal/ first-listed diagnosis.” On that list, you’ll find Z51.1- (Encounter for antineoplastic chemotherapy and immunotherapy). This means your ICD-10-CM coding should sequence Z51.11 (Encounter for antineoplastic chemotherapy) as the principal diagnosis before the cancer diagnosis code — in this case C61 (Malignant neoplasm of prostate) as you have stated. This would then provide medical justification for the treatment and drug codes, which you have correctly given as 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic) and J9217 (Leuprolide acetate (for depot suspension), 7.5 mg).
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Check This Principal Dx Guideline for Chemo Denial
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