Oncology & Hematology Coding Alert

Question: A patient had a colonoscopy due to a personal history of colon polyps. They had a previous colonoscopy two years ago. That procedure found no colon polyps, and there were no colon polyps found on this recent colonoscopy. So, we billed using Z86.010 and G0105. The patient’s primary insurance denied the claim because the “ICD-10 is an unacceptable principal diagnosis.”

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Answer: The reason for 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.