Wiki Encounter for Chemo, Radio or Immunotherapy Code Sequencing

[elizabeth24]

Coding rules state that if a patient is seen for the administration of chemo, immuno or radiotherapy we are to sequence the appropriate Z code (encounter for) primary and the malignancy codes are secondary. We are having a lot of commercial insurances deny for high dollar drugs, and the insurance company is stating that we need to re-sequence the codes to make the malignancy codes primary and the Z code for the encounter secondary. I have never experienced this before, and that violates the coding rules and regulations. Our billers as well as our CDI have asked me to change the sequence of these codes so insurance will pay. I have never been in this situation before, so I am unsure what information is accurate.

Can insurance companies request codes to be changed around to not meet the coding rules an regulations and we as coders are to do this?
Do payer rules trump coding rules and regulations?
Has anyone else experienced this, and if so, how do you handle the situation?

I am not comfortable just changing codes around because someone tells me to, however, if there is a validity to this and I should be doing what the insurance companies are requesting then I want to do so. I am just trying to find some reliable and accurate information to handle this situation and what is accurate and correct as far as coding goes.

Any information or advice would be greatly appreciated!!

 

[thomas7331]

If the payer has written and published policies about how they want their claims coded, I'd be comfortable changing the coding to align with their policies, assuming codes are supported by documentation. I would not change coding just based on what a payer rep has said on a phone call, however. They are usually not certified coders and do not always give correct information. Absent a written policy, payers shouldn't reject correctly coded claims that are covered benefits, and if they're doing that then the issue should be escalated. If your payers are not following correct coding rules and not giving any written direction, then it should be addressed with you payer representatives.

At the same time, getting large payers to make changes can be a slow or impossible task, so you may have no other choice. If the payer has no written policy and there is no other way to get the claim paid, I think that sequencing is a relatively minor issue in this particular situation. Though you are technically violating a coding rule, you aren't really submitting a fraudulent claim if all of your codes are supported by what's in the medical record. (It would be a little different, for example, if your encounter is a behavioral health service and you are resequencing it with an incidental medical diagnosis to get it paid under medical benefits. In your case, the entire claim is related to the treatment of the malignancy.)

However, this isn't something you want to become a habit, and it's best to be open and up front with what you're doing and initiate a discussion with the payer about the problem, so that you don't end up being accused of doing something improper down the road.

Just my thoughts - hope it may help some.

 

[elizabeth24]

If the payer has written and published policies about how they want their claims coded, I'd be comfortable changing the coding to align with their policies, assuming codes are supported by documentation. I would not change coding just based on what a payer rep has said on a phone call, however. They are usually not certified coders and do not always give correct information. Absent a written policy, payers shouldn't reject correctly coded claims that are covered benefits, and if they're doing that then the issue should be escalated. If your payers are not following correct coding rules and not giving any written direction, then it should be addressed with you payer representatives.

At the same time, getting large payers to make changes can be a slow or impossible task, so you may have no other choice. If the payer has no written policy and there is no other way to get the claim paid, I think that sequencing is a relatively minor issue in this particular situation. Though you are technically violating a coding rule, you aren't really submitting a fraudulent claim if all of your codes are supported by what's in the medical record. (It would be a little different, for example, if your encounter is a behavioral health service and you are resequencing it with an incidental medical diagnosis to get it paid under medical benefits. In your case, the entire claim is related to the treatment of the malignancy.)

However, this isn't something you want to become a habit, and it's best to be open and up front with what you're doing and initiate a discussion with the payer about the problem. so that you don't end up being accused of doing something improper down the road.

Just my thoughts - hope it may help some.

Thank you, that is very helpful. I have been coding for 15+ years, and I have never encountered this issue before now. I will pass the information along and see what the others think. Thanks

 

[chantal777]

Thank you, that is very helpful. I have been coding for 15+ years, and I have never encountered this issue before now. I will pass the information along and see what the others think. Thanks

Elzabeth24,

this is from coding guidelines, maybe you could send them the coding guidelines to educate them.
Admission or Encounter Involving Administration of Radiation Therapy, Immunotherapy, or Chemotherapy

When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as the first-listed or principal diagnosis.

When 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; Z51.11, Encounter for antineoplastic chemotherapy; or Z51.12, Encounter for antineoplastic immunotherapy, as the first-listed or principal diagnosis.

 

[trarut]

Agree with Thomas. Most important to remember is that payers can always set their own rules, as evidenced by requiring 59 modifiers on add-on codes that are 59 modifier exempt per CPT. For years, Anthem wouldn't pay for epo products unless the anemia code was listed first - primary or secondary. They didn't care what ICD said about sequencing. It had to do with what their system could handle and, in this instance, it would only read the first listed code. We could either flip the ICD code order for the Anthem plans or go unpaid. We chose to flip the code order as we knew it was something the payer wasn't going to fix.

Sometimes you have to pick your hill. Make it a hill worth picking.

 

[elizabeth24]

Elzabeth24,

this is from coding guidelines, maybe you could send them the coding guidelines to educate them.
Admission or Encounter Involving Administration of Radiation Therapy, Immunotherapy, or Chemotherapy

When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as the first-listed or principal diagnosis.

When 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; Z51.11, Encounter for antineoplastic chemotherapy; or Z51.12, Encounter for antineoplastic immunotherapy, as the first-listed or principal diagnosis.

I have shared this information with our billers. It has basically come down to getting paid versus not getting paid

 

[elizabeth24]

Agree with Thomas. Most important to remember is that payers can always set their own rules, as evidenced by requiring 59 modifiers on add-on codes that are 59 modifier exempt per CPT. For years, Anthem wouldn't pay for epo products unless the anemia code was listed first - primary or secondary. They didn't care what ICD said about sequencing. It had to do with what their system could handle and, in this instance, it would only read the first listed code. We could either flip the ICD code order for the Anthem plans or go unpaid. We chose to flip the code order as we knew it was something the payer wasn't going to fix.

Sometimes you have to pick your hill. Make it a hill worth picking.

I am not sure how I can communicate this information with others. The other OP coders go strictly by the coding rules and guidelines as well. It's frustrating because no one can give me a solid yes or no on what is the correct thing to do.

 

[trarut]

I am not sure how I can communicate this information with others. The other OP coders go strictly by the coding rules and guidelines as well. It's frustrating because no one can give me a solid yes or no on what is the correct thing to do.

I get it but I always explain to my staff that coding rules are black and white but the payers introduce a gray area and it's not always as simple as yes or no. As coders, we know the right thing to do is to follow the coding guidelines but I agree with Thomas that if the payer has a published policy stating they want something different, the payer guideline should supercede the coding guideline. Do you have a compliance manager? This might be something to discuss with them so that a decision can be made at the organizational level. That way you have a policy and all coders are on the same page.

 

[thomas7331]

I have shared this information with our billers. It has basically come down to getting paid versus not getting paid

The billing department and the payers should not dictate how you code. But on the other hand, if your practice is not getting paid, then someone at a higher level of management needs to make a decision as to how to proceed - either do what needs to be done to get paid and accept the potential compliance risks that might come with that, or work with the payer to resolve the problem, or accept the loss in revenue. This is a business decision - it shouldn't be up to the individual coders and billers to work this out - the practice leadership needs to give you their direction on what to do.

 

[kathleeng]

Coding rules state that if a patient is seen for the administration of chemo, immuno or radiotherapy we are to sequence the appropriate Z code (encounter for) primary and the malignancy codes are secondary. We are having a lot of commercial insurances deny for high dollar drugs, and the insurance company is stating that we need to re-sequence the codes to make the malignancy codes primary and the Z code for the encounter secondary. I have never experienced this before, and that violates the coding rules and regulations. Our billers as well as our CDI have asked me to change the sequence of these codes so insurance will pay. I have never been in this situation before, so I am unsure what information is accurate.

Can insurance companies request codes to be changed around to not meet the coding rules an regulations and we as coders are to do this?
Do payer rules trump coding rules and regulations?
Has anyone else experienced this, and if so, how do you handle the situation?

I am not comfortable just changing codes around because someone tells me to, however, if there is a validity to this and I should be doing what the insurance companies are requesting then I want to do so. I am just trying to find some reliable and accurate information to handle this situation and what is accurate and correct as far as coding goes.

Any information or advice would be greatly appreciated!!

Guidelines may state one way but there are payer specific guidelines that can vary in some circumstances. Some payers want the encounter codes primary, while others want it secondary. Example in my area most payers including Medicare wants the malignancy code primary, along with Z51.11 secondary, but Tricare, Molina, and Health Net want it opposite.