Oncology & Hematology Coding Alert

Question: ICD-10-CM coding guidelines state that if a patient is seen for the administration of chemo-, immuno- or radiotherapy, we are to sequence the appropriate Z, or encounter, code for the primary diagnosis and the malignancy codes for the secondary. However, a lot of commercial insurances are denying, stating that we need to re-sequence the codes to make the malignancy codes primary and the Z code for the encounter secondary.

Can insurance companies request codes to be changed around so they do not meet the coding rules and regulations? And can we, as coders, do this?

AAPC Forum Participant

Answer: Your reading of the ICD-10-CM guidelines is correct. Guideline I.C.2.e.2. states that “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.”

However, if a payer is asking you to not follow a guideline, and the payer has written or published policies about how they want their claims coded, you may have no choice but to follow the payer’s rule if you want to get paid. In this instance, while you may technically be violating the guideline, sequencing is a relatively minor issue, and if all of your codes are supported by what’s in the medical record, you aren’t submitting a fraudulent claim.

Alternatively, if the payer does not have a written policy, the payer should not reject correctly coded claims. In this instance, you should address the issue directly with the payer and provide ICD-10-CM guideline documentation to support your claim. You should also request their policy on how codes should be reported to the payer in writing.