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Andyleed90

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Hello all,

I recently did an audit for a doctors office. The provider ordered TSH, Lipid panel and PSA Screening. He provided only a Z00.00. I coded it out to that because I was always under the impression that for outpatient, Z00.00 can be used for PSA Screenings. I can see why the other two were denied but I am confused about the PSA screen. I have been coding most PSA screens to the Z12.5 but there have been a few over the past few months that only gave a Z00.00 in their documentation. This is the first instance that I have gotten it denied. Any thoughts? I am so confused. Thank you!
 
you should not use Z00.00 for labs. The payers want to know the reason for the labs as all screenings are not covered. If these were for screening purposes then use the appropriate screening Z code, if the patient is on a medication for a diagnosed problem and that is the reason for the lab then use the Z51.81 with the appropriate Z79 code for the type of drug. the provider needs to indicate, in the encounter note, the reason for the labs that are ordered.
 
That makes sense. I have seen many cases though with Medicare and medicare advantage plans that they will deny when only Z codes are used no matter the combination, be it screening/hx/or z00. The medication aspect is interesting though, thank you!
 
Hi,
Lab procedure are not meant to be billed with dx z00.00 - Encounter for general adult medical examination without abnormal findings.
its like if everything is abnormal then why provider has ordered lab ? but it does mean that we can bill z00.01 either .

if lab is done for screening use appropriate screening codes.
commercial payor will pay for screening dx 9 not all payors), Medicare does not pay for screening dx .
 
if the provider discovers an abnormality that requires testing then you would use the abnormal finding diagnosis as the medical necessity for the lab not Z00.01.
It does not matter what a payer will cover when it comes to coding the services that have been rendered, it matters that we code the correct diagnosis for the service rendered. When The patient presents for a preventive visit it is the responsibility of the patient to know what they have coverage for. Most payers do limit the coverage of screening tests. When The provider orders screening tests to be performed the provider must tell the patient in detail what tests have been ordered so the patient can decide whether they want to follow thru with screenings knowing what is and is not covered.
I was in a hotel not long ago and one of the hotel cleaning staff was in the ladies room in tears. She had gone for her annual exam and they had drawn blood for screening tests but then she received a bill for $1200 for all the tests performed that were not covered. She was devastated. She said she was only told they were going to do her routine annual screening tests and they were a part of her annual. She never thought anything about it and then got the bill. I told her she was not liable to pay for it since they never explained what tests they were performing. I showed her in her plan where it laid out exactly which tests were covered. She had taken that paperwork with her even and showed the staff that she had insurance and it included preventive coverage and right there on that page it indicated the 3 tests she was covered for.
Sorry I will get off my soapbox now! I feel we must do better at the point of service to prevent this kind of thing from happening. But when the coder gets it, it is all over with and the coder has the responsibility to code it correctly regardless of coverage.
 
So if it is up to the doc at the point of service to explain what will be covered, was she able to waive the bill?
 
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