General Category > General Questions
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:
--- Quote from: leanersnail4 on September 27, 2018, 12:18:46 PM ---
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?
--- End quote ---
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.
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