Oncology & Hematology Coding Alert

Question: We provided prophylactic radiation therapy on a lung cancer patient’s brain. When we billed Medicare using Z41.8, we got denied. A colleague suggested I use Z29.8. Is this correct, or should I resubmit the claim with different code?

AAPC Forum Participant

Answer: While Z29.8 (Encounter for other specified prophylactic measures) is a more appropriate code to use in this situation than Z41.8 (Encounter for other procedures for purposes other than remedying health state), the issue here may be one of providing the correct diagnosis code and sequencing that code with the encounter code.

Providers often perform prophylactic cranial irradiation (PCI) on patients who may not have, but who run the risk of, metastatic brain cancer due to current small-cell lung cancer (SCLC). Because of this, payers will want to see that the patient is responding to treatment for the SCLC, and that the patient’s current condition meets their requirements for PCI coverage.

That means you will have to provide a diagnosis code for the SCLC from the C34.- (Malignant neoplasm of bronchus and lung) codes, specifying the exact laterality and lobe of the cancer or whether the cancer exists in overlapping sites or an unspecified site.

Then you will have to check your payer’s preference for sequencing the codes. Some will require the diagnosis code first, with the encounter code as the secondary code, while others will require the opposite. So, you should fully understand your payer’s requirements for PCI and seek prior authorization for the PCI claim before submitting.