Oncology & Hematology Coding Alert

Question: We have been getting denials recently from Blue Cross Advantage Plus in Michigan. We have always used a cancer diagnosis code as primary with 96402 along with other administration codes. Suddenly, we are getting denials — not always consistent — stating that the diagnosis code used (the cancer code) is invalid. It now appears they want a Z51.- code as primary for these. Is this correct or is it just their policy?

AAPC Forum Participant

Answer: Blue Cross’ policy in this instance is absolutely correct as it is taken directly from the ICD-10-CM guidelines I.C.2.e.2, which states:

If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or external beam radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis.

This means you should always be using a Z51.- (Encounter for other aftercare and medical care) code as a first-listed diagnosis, particularly Z51.11, when the purpose of the encounter is to administer chemotherapy and you are also reporting a chemotherapy administration code such as 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic). If you’re not currently using a Z51.- code as the primary diagnosis for such encounters, you may want to start or you could get push back from other payers down the road too.