General Category > General Questions
PREVENTIVE COLONOSCOPY PATHOLOGY (TC) GENERATING COPAY Z86.010
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:
--- Quote ---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.
--- End quote ---
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.
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