Pathology/Lab Coding Alert

Master diagnosis and frequency limitations.

Payers may approve many different testing methods to screen patients for early detection of colorectal cancer (CRC), but if you miss the rules about which test, how often, and for what diagnosis, you could end up holding the bag for the costs.

Use the following tips and tools to make sure your lab captures all the pay you deserve for CRC screening.

Tip 1: Use Screening Diagnosis Code

Physicians order screening tests in the absence of signs or symptoms of disease, and that includes the absence of prior test results or medical history that might impact the need for CRC testing.

When a patient meets those criteria, you should see that clinicians order screening CRC tests with one of the following diagnosis codes:

• Z12.11, Encounter for screening for malignant neoplasm of colon
• Z12.12, Encounter for screening for malignant neoplasm of rectum.

Not this: On the other hand, if the patient has symptoms or test findings, such as blood in the stool, you cannot bill » » for a screening test, but should instead use the appropriate ICD-10 code for the condition, such as R19.5 (Other fecal abnormalities).

Indicate risk: Other ICD-10 codes might indicate that the patient is at high risk for developing CRC, and this may allow for more frequent screening tests. Here are some relevant diagnosis codes you should know:

• Z85.030, Personal history of malignant carcinoid tumor of large intestine
• Z85.038, …other malignant neoplasm of large intestine
• Z85.040, …malignant carcinoid tumor of rectum
• Z86.010, Personal history of colonic polyps
• Z80.0, Family history of malignant neoplasm of digestive organs
• Z83.71, Family history of colonic polyps
• K50.-, Crohn’s disease…
• K51.-, Ulcerative colitis…

Tip 2: Observe Frequency Guidelines

The following table illustrates how often clinicians can order screening CRC tests for Medicare and many other payers.

Tip 3: Code Findings Second

If the lab evaluates a specimen for a screening CRC test that results in positive findings, you’ll still need to report the screening ICD-10 code first and sequence any findings as a secondary diagnosis code.

For instance: You need to be accurate in sequencing ICD-10 codes for screening colonoscopy that ends up therapeutic, says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ. There would be two diagnosis codes in your claim:

• First, report the screening ICD-10 code Z12.11
• Next, report the appropriate ICD-10 code for pathology findings for the excised specimen, such as D12.- (Benign neoplasm of colon, rectum, anus and anal canal…).