PREVENTIVE COLONOSCOPY PATHOLOGY (TC) GENERATING COPAY Z86.010

[leanersnail4]

Hello, I work in health insurance and I am having trouble wrapping my head around why only one of four claims is generating a copay.

Surgery Facility - Paid in Full
Line 1 CPT 45385 Modifier: 33  Z86.010
Line 2 CPT 45380 Modifier: 33  Z86.010

Surgery Physician - Paid in Full
Line 1: CPT 45385    Modifier: 33   Z86.010 K63.5 K57.30 K64.0
Line 2: CPT 45380    Modifier: 33   Z86.010 K63.5

Pathology Professional Component  - Paid in Full
CPT 88305 Modifier: 26   Z86.010, D12.2

Pathology Technical Component - Generated a copay
CPT 88305 Modifier: TC    Z86.010, D12.2


Primary Diagnosis: Z86.010 - Personal history of colonic polyps
Secondary Diagnosis: D12.2 - Benign neoplasm of ascending colon


My question: is there anything that can be done regarding the claim generating a copay?  From my understanding, a 33 or PT modifier is needed
to be considered preventive and paid in full.  It's seems odd that three of the four claims are paying in full, but one is generating a copay.

Thank you,
Anthony

[Michele]

In your question you stated that you believe the 33 modifier is needed but it is not on the pathology charges.  Are you the patient?  Since all four of these claims would be billed by 4 different providers I'm just wondering how you happened to have the coding info on all.  It's not that I care, but it helps in knowing how to answer you.  If I were the patient of the scenario below I would contact my insurance carrier to ask why I'm being charged a copay on the one service.  If I were the biller responsible for the service charging the copay and I didn't believe that was correct I would contact the insurance carrier to ask if there was an error in processing or if the 33 modifier was needed.

It is not uncommon for insurance carriers to process claims incorrectly (which I'm sure you know since you said you work in health insurance).  It's also possible they require something to indicate that the service was preventative. 

I hope that is helpful.

[leanersnail4]

Thank you for the reply.

To clarify, I work in customer care of the members health insurance company.  This allows me access to the claims.  The member called with a bill. 

Based on my resources, in order for the pathology to be covered in full it must have a 33 or PT modifier.  I have not sent the claim for adjustment review..however, I do not believe an adjustment would occur if I did based on processing error.  Potentially, one of the following diagnosis codes could cover the claim as preventive as well: Z12.10 or Z12.11 or Z12.12 (not submitted on any of the claims)

So I guess what I'm asking is; is a claim re-submission ever appropriate for the technical component of the claim, either with an updated modifier or an updated Dx code?

[leanersnail4]

I also found this link which may be helpful:  It seems similar to my issue. 

https://www.aapc.com/memberarea/forums/135955-z12-11-vs-z86-010-a.html

[Michele]

Based on my resources, in order for the pathology to be covered in full it must have a 33 or PT modifier.  I have not sent the claim for adjustment review..however, I do not believe an adjustment would occur if I did based on processing error.  Potentially, one of the following diagnosis codes could cover the claim as preventive as well: Z12.10 or Z12.11 or Z12.12 (not submitted on any of the claims)

So I guess what I'm asking is; is a claim re-submission ever appropriate for the technical component of the claim, either with an updated modifier or an updated Dx code?

Yes a claim re-submission would be appropriate if information on the original claim needs to be corrected, even on the technical component of a claim.  It sounds (based on your description) that it would be appropriate in this case.

[leanersnail4]

I believe I understand why the claim is generating a copay based on how our claim system is configured. 

-The surgery claims are paying in full because of the 33 modifier.  These override the Dx codes.
-The Professional Component (26 modifier) is paying in full because regardless of the service, when there is a technical component and a professional component billed...the technical component generates a copay and the professional component does not (excluding deductible based plans).
-For the Technical component which is generating a copay, because there is no preventive modifier (33/PT) or preventive diagnosis billed (Z12.10 or Z12.11 or Z12.12), it is generating a copay.
*I ran a report of claims by the provider and any technical component claim of the same type of claim/contract only pays in full with the following diagnosis (Z12.10 or Z12.11 or Z12.12) and will generate a copay/deductible when billed with diagnosis (Z86.010, D12.2).

*One last question:  Can a technical component of a claim be re-billed with only a 33 or PT modifier?  Can multiple modifiers be submitted on one CPT code?  Or is an updated Dx code only way claim can be resubmitted because it needs to be configured with the TC modifier?

[Michele]

You can have up to 4 modifiers on a line (per cpt code).  You are able to add the 33 or PT modifier and still have the TC modifier.  You can update the diagnoses as well if you wish.

[leanersnail4]

Thank you for the insight Michele, very helpful !!

[PMRNC]

To clarify, I work in customer care of the members health insurance company.  This allows me access to the claims.  The member called with a bill.

Are you supposed to be advising the patient on how the provider should code. I only ask because I've worked at 3 carriers and that was a huge no-no. As claims examiner and even our customer service rep's had to refer them to the physician. We could explain how we processed the claim but we can't tell them how their providers should have coded them. If you are just a rep I would either have the claims examiner who processed claim help you explain to patient (though I think your explanation nailed it) or if your company allows you to have them speak to the patient directly have them explain it.
 

 

[leanersnail4]

Yes, my hands are tied when it comes to discussing the specifics with the patients/providers.  Although, I try to provide hints.

If the copay applies and cannot be changed, my explanation to the patient will be "Based on how the claim was configured, it is not processing as a preventive service and the copay is applicable." 

When I discuss this with the provider, I am going to ask why a diagnosis of  Z12.10 or Z12.11 or Z12.12 or a modifier of PT/33 is not appropriate for this members screening.  And request the chart notes on the services to be reviewed to see if a re-submission may be appropriate.

[PMRNC]

When I discuss this with the provider, I am going to ask why a diagnosis of  Z12.10 or Z12.11 or Z12.12 or a modifier of PT/33 is not appropriate for this members screening.  And request the chart notes on the services to be reviewed to see if a re-submission may be appropriate.

Be careful if they screen calls. Instead of asking them why they didn't code something a certain way I would tell them to appeal with the notes and leave it at that. Even with hints it can be encouraging fraud as they could take your hint and change documentation. JMHO..I was  a senior tech claims advisor at the last carrier I worked for. Rep calls were always screened, they didn't always review all of them but they could at any time. You also never know if a diff claims person comes along to review the notes and denies, first thing doctor is going to do is call back and whether you said it or not, they will say you told them what to do. Now working for doctors I constantly have patients either LIE or misunderstand the carrier, calling me and telling me the carrier said they didn't code the visit right. HAPPENS all the time!!!

[leanersnail4]

You are absolutely right, I did not think about the call being pulled.  I will need to revisit my strategy.  I want to stay compliant and follow correct protocol.

From my understanding, a claim can only be appealed if there is a denial.  This claim is not denying and the member called in because it generated a copay.  Perhaps you have some insight what capabilities the providers have?  I can only speak of the members appeal rights.  Thanks.

[PMRNC]

From my understanding, a claim can only be appealed if there is a denial.  This claim is not denying and the member called in because it generated a copay.  Perhaps you have some insight what capabilities the providers have?   

Any time a claim pays less than the "billed" charges there is an adverse benefit and can be appealed. I too suffered the "insuarnce company brain wash" <g>  I still miss it though..
They can appeal a claim they believe was processed incorectly.

I can only speak of the members appeal rights.  Thanks.

On the contrary.. all you have to do is think on the side of the patient and/or the provider. Anytime they "think" they were not paid fairly they can appeal. Of course that doesn't mean the claim will pay upon an appeal but they can appeal. When i went from being claims examiner to billing I had to do a lot of adjusting on how I thought of claims. I had to jump over to the other side and it wasn't always easy.

[leanersnail4]

Thank you for insight on the provider protocol. I need to know the "why" behind things and I want to communicate the correct answer to the patient (while remaining compliant).  Claims often process against expectations and I am making every effort to ensure the members contract is being honored. 

I have been working in health insurance with a focus on member care for three years now and I still believe they can only appeal denied claims (except Medicare members).  Although, I agree with the idea a patient should be able to appeal any claim that they do not feel the insurance company is not paying fairly, this does not seem to be the case.

For what its worth, I performed a quick google search and the results support appeal rights only exist for denied claims as well.  Would you happen to have any resources which support your statement that a member can appeal any claim they do not feel is processing correctly?

[PMRNC]

My intent isn't too argued but I'll give you an example. A surgical procedure for $900 is submitted, provider is non-par. Insurance company pays $600 with $100 going towards the patient's deductible and $500 is above U&C.   That $500 is what is called an "adverse" benefit. If you look at any of the EOB's your carrier produces you will notice they use the word "Adverse benefit" (Especially on ERISA group health plans) An adverse benefit determination is defined as;

An "adverse benefit determination" is: (1) a denial, reduction or termination of a benefit; (2) a failure to provide or pay for a benefit (in whole or in part); (3) a denial of participation in the plan.

An appeal can be made on any adverse benefit determination. Anything NOT paid in full can be appealed. Again, not saying it will be paid, just that member can appeal.