Wiki Lynch Syndrome Z15.09

[tinafields]

With the recent change in ICD-10 guidelines, this code can no longer be used in the primary position. I have a patient that has been having colonoscopies every year and EGD's every 3 years based on this diagnosis. Does anyone know what ICD-10 code can be used as a primary diagnosis when there is no other indication for the exams? We will also need to prior-auth the EGD and this is making things very difficult. Any help you could give me would be greatly appreciated!

 

[SharonCollachi]

Found this: To code Lynch Syndrome, you should report V84.09 (Genetic susceptibility to other malignant neoplasm). Lynch Syndrome, also called hereditary nonpolyposis colorectal cancer (HNPCC), is an inherited condition that increases a patient’s chance of getting colon cancer as well as several other cancers. You may need additional codes to complete the coding. For instance, if the patient currently has a malignant neoplasm, you should code that neoplasm first, such as 153.6 (Malignant neoplasm of ascending colon). Or if the patient has a history of a malignant neoplasm, you should report a code to indicate this, such as V10.05 (Personal history of malignant neoplasm of large intestine). Given the nature of the condition, perhaps the patient has family history of cancer documented. If so, you should report this, as well, using the appropriate code, such as V16.0 (Family history of malignant neoplasm of gastrointestinal tract).

ICD-10-CM: Under ICD-10-CM, the codes above would crosswalk to:

· C18.2, Malignant neoplasm of ascending colon
· Z15.09, Genetic susceptibility to other malignant neoplasm
· Z85.038, Personal history of other malignant neoplasm of large intestine
· Z80.0, Family history of malignant neoplasm of digestive organs.


And from Medicare (although it says genetic testing, it still has codes).

 

[thomas7331]

In my opinion, if the patient has no active disease or malignancy requiring treatment or surveillance but only a genetic susceptibility, this would be a screening examination, and the appropriate first-code would be the Z12.11, with the Z15.09 as an additional code to demonstrate the high risk status and (hopefully) support the necessity of the more frequent than usual interval for the procedure. The colonoscopy is not being performed to treat the Lynch Syndrome, but rather is for the purposes of early detection of malignancy like any other screening, so it wouldn't be appropriate to code they Lynch Syndrome as primary, even if it were possible. I realize that this may present challenges with some payers, however.

 

[tinafields]

In my opinion, if the patient has no active disease or malignancy requiring treatment or surveillance but only a genetic susceptibility, this would be a screening examination, and the appropriate first-code would be the Z12.11, with the Z15.09 as an additional code to demonstrate the high risk status and (hopefully) support the necessity of the more frequent than usual interval for the procedure. The colonoscopy is not being performed to treat the Lynch Syndrome, but rather is for the purposes of early detection of malignancy like any other screening, so it wouldn't be appropriate to code they Lynch Syndrome as primary, even if it were possible. I realize that this may present challenges with some payers, however.

Thank you for your recommendation! This is helpful, however I am still unsure how to get the EGD covered as you cannot do that for a screening. Another post stated I should use V84.09 for both, and I will see if this will work for my EGD prior-auth. Much appreciated!

 

[thomas7331]

Thank you for your recommendation! This is helpful, however I am still unsure how to get the EGD covered as you cannot do that for a screening. Another post stated I should use V84.09 for both, and I will see if this will work for my EGD prior-auth. Much appreciated!

V84.09 is not a valid ICD-10 code so that is not going to work (V84.09 is the ICD-9 code corresponding to Z15.09).

You're correct, an EGD is not typically covered as a screening procedure. But whether or not something is covered is entirely up to the insurance plan that is paying for the procedure - it's not a coding problem. You can only code from what is documented in the record as the symptoms and or diagnoses that are present at the encounter. It's not up to a coder get something covered - it's either covered for that condition or it's not.

My suggestion would be that if the payer is insisting this service is not covered based on the codes that can be reported for the conditions that this patient has, it may be necessary to have the patient and provider work together to request a benefit exception from the plan. If that fails, then it is really up to the patient to decide whether or not they want to pay for this procedure out of pocket.

 

[zcometa]

Found this: To code Lynch Syndrome, you should report V84.09 (Genetic susceptibility to other malignant neoplasm). Lynch Syndrome, also called hereditary nonpolyposis colorectal cancer (HNPCC), is an inherited condition that increases a patient’s chance of getting colon cancer as well as several other cancers. You may need additional codes to complete the coding. For instance, if the patient currently has a malignant neoplasm, you should code that neoplasm first, such as 153.6 (Malignant neoplasm of ascending colon). Or if the patient has a history of a malignant neoplasm, you should report a code to indicate this, such as V10.05 (Personal history of malignant neoplasm of large intestine). Given the nature of the condition, perhaps the patient has family history of cancer documented. If so, you should report this, as well, using the appropriate code, such as V16.0 (Family history of malignant neoplasm of gastrointestinal tract).

ICD-10-CM: Under ICD-10-CM, the codes above would crosswalk to:

· C18.2, Malignant neoplasm of ascending colon
· Z15.09, Genetic susceptibility to other malignant neoplasm
· Z85.038, Personal history of other malignant neoplasm of large intestine
· Z80.0, Family history of malignant neoplasm of digestive organs.


And from Medicare (although it says genetic testing, it still has codes).

Here is an updated link to Medicare guidance for genetic testing