Author Topic: DX for blood tests  (Read 310 times)

Kerri

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DX for blood tests
« on: March 03, 2021, 01:55:39 PM »
We do a TON of yearly physicals here.  I am having alot of patients call complaining that their bloodwork is not being paid for by their insurance (all kinds of insurance).  The diagnosis code on the order for almost every test is Z13.0, screening for disorders of the blood.  The doctors here have used it for years. NOW all of the sudden its not getting paid.  Today Aetna told a patient that Z13.0 isn't a "real" diagnosis.

Is anyone else having this problem?  What dx do you use when ordering a CMP?
A lipid profile?  a Hep C?   A BMP?

Michele

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Re: DX for blood tests
« Reply #1 on: March 04, 2021, 09:40:27 AM »
I haven't billed for bloodwork however, I researched it a bit.  Z01.812 was introduced on 10/1/2020 as a "diagnosis of encounter for preprocedural laboratory examination".  Are you familiar with that code?
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Kerri

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Re: DX for blood tests
« Reply #2 on: March 04, 2021, 11:28:37 AM »
Yes, I am, but these are not pre proceedural exams.  These are yearly physicals

RichardP

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Re: DX for blood tests
« Reply #3 on: March 04, 2021, 03:36:14 PM »
A couple of generic points here, for those passing by later:

1.  Z01.812 was not introduced on 10-1-2020.  It has been around for a while.  I have that code in our database of codes that we use frequently.  I've been using that database for a number of years.  I can find articles on the internet dated, for example, in 2018 that reference Z01.812.

2.  The fiscal year for the U.S. Government begins on 10-1 of every year.  Medicare is part of the U.S. Government, which may explain Point 3, at least for the United States.

3.  10-1-Current year (e.g., 2020) is the date that the ICD-10 code set becomes official for the following calendar year (e.g., 10-1-2020 is the date that the ICD-10 code set for 2021 becomes official).

4.  Kerri - consider the difference between "looking for a disease" and actively "managing a disease".  There are screening codes ("looking for a disease") that Medicare won't pay for, which influences commercial health insurance carriers decision making on what they will pay for.

The logic is that:

 - "looking for a disease" is part of a general evaluation that is often considered paid for by using the office visit code.

 - "managing a disease" is actually trying to mitigate the effects of the disease on the patient.  So, for example, a person already diagnosed with DM II would require periodic checks for blood sugar levels by the provider.  So provider orders appropriate blood test for blood sugar level (using CPT Code, say 83036).  The DX code to get that test paid would be one of the DX codes for Diabetes (say, DX code E11.8 ).  A person already diagnosed with hypertension or hyperlipidemia requires periodic checks for blood lipid levels by the provider.  So provider orders a lipid panel (using CPT Code 80061).  The DX Code(s) to get that test paid would be, say, the DX code for hypertension (I10) or hyperlipidemia (E78.5), or both.  Likewise, provider would order a Hepatic Panel (CPT 80076) to monitor whatever problems the patient has with abnormalities of liver function (various DX codes for that).

In all of the examples here, we are running blood tests to manage diseases, we are not running blood tests looking for diseases.

5.  Efforts to manage a disease should be part of the ongoing patient/doctor relationship over the course of a year (multiple visits to assess through blood and urine tests the outcomes of the disease management routine developed between doctor and patient).

If you get this logic, then you might better understand why a yearly physical is considered a different animal than the ongoing disease management.  And so different codes are required for each.

6.  Note that we do yearly physicals (Commercial or Medicare) and annual wellness (or follow-up) exams (Medicare) and do blood work (CPT).  But, in such cases, we always code that bloodwork with DX codes that indicate the diseases unique to that patient that have already been identified and are being managed by the blood work tests ordered.

We do our best to stay away from "Screening" codes.  That is, we may use a screening code (e.g., Screen for DM - Z13.1), but we don't rely on it.  If we use a screening code, we also code for the reasons why we are doing the screening for DM - Fatigue (R53.83); Nocturia (R35.1); Urinary Frequency (R35.0) and Abnormal Glucose (R73.09).  All of those symptoms are indicitive of DM, and support the screening for DM through the appropriate blood tests ordered.

Find those DX codes, and others, here:
http://www.icd10data.com/ICD10CM/Codes

Kerri

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Re: DX for blood tests
« Reply #4 on: March 04, 2021, 06:07:58 PM »
RICHARD

I get that, and my docs do use specific dx when they manage what the patient already has. But These physicals are done yearly and required by the practice if you want to keep getting your meds.  I have been trying to get them to use actual diagnosis' but they keep going back to Z13.0 and saying they aren't looking for anything SPECIFIC, they want to see if anything shows up.

Michele

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Re: DX for blood tests
« Reply #5 on: March 04, 2021, 07:25:40 PM »
Thanks Richard!  I don't encounter this.  I did a quick research on it but today was crazy.  I just tried to find what I was looking at and don't see it now.  So I'm not sure what I was looking at but thanks for the info.  Hopefully you are able to help Kerri with her other question.  Sounds like insurance doesn't cover labs unless there is a reason for the dr to order them?
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kristin

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Re: DX for blood tests
« Reply #6 on: March 05, 2021, 02:13:32 AM »
My two cents, from when I billed for an IM doc a few years back:

Contact the facilities your patients are going to for their BW (Quest, LabCorp, etc) and ask them for a list of covered diagnoses for the various BW tests your docs are writing orders for.

 Once you get that list, if a diagnosis on it for a particular BW test is legit for a patient, use it. If not, unfortunately that patient may have to pay out of pocket for their BW.

Some insurances just will not pay for screening dx's, they will only pay if a patient has a documented condition that is being monitored/treated, such as hyperlipidemia, hypothyroidism, Vit D deficiency, etc.

RichardP

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Re: DX for blood tests
« Reply #7 on: March 05, 2021, 03:19:45 AM »
Some insurances just will not pay for screening dx's ...

Yes.  Medicare doesn't pay for many / most screenings, and the Commercial Carriers follow suit.  Which is why I gave the example about screening for DM2 above (CPT 83036).  Why use a screening code Z13.1 as the reason for the blood test when, to quote myself from above, Fatigue (R53.83); Nocturia (R35.1); Urinary Frequency (R35.0) and Abnormal Glucose (R73.09) are all symptoms indicitive of DM, and support the screening for DM through the appropriate blood tests ordered.  Assuming those conditions actually apply to the patient.  If those conditions are not present, and the provider uses a screening code, Medicare assumes the provider is just padding his income by screening for something when the other symptoms are absent and that absence then does not support the need for screening.  I've focused on DM2 here, but the same logic applies to other blood tests.  There should be physical symptoms visible that lead one to conclude that a blood test is in order.  Code for those physical symptoms and tie them to the blood test.  Takes away the need for a screening code.

Michele said "Thanks Richard!"

Richard says - you're welcome Michele.

RichardP

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Re: DX for blood tests
« Reply #8 on: March 05, 2021, 03:49:43 AM »
I get that, and my docs do use specific dx when they manage what the patient already has.

But These physicals are done yearly and required by the practice if you want to keep getting your meds.

I have been trying to get them to use actual diagnosis' but they keep going back to Z13.0 and saying they aren't looking for anything SPECIFIC, they want to see if anything shows up.

Kerri - are the medications re-authorized only once per year for a particular condition???  If the reason for the blood test is to re-authorize medications, they damn well better be looking for, and finding, something specific.  Elsewise, what is the justification to re-authorize the medications?

It is at this point that the conversation about blood tests splits away from general logic and gets into specific details about any given disease.  Some diseases are chronic and can never be cured, so they must be managed long-term for the comfort of the patient.  In these cases, the symptoms that supported the original CPT Code for blood test should still be visible, but hopefully at a lesser level.  Those original DX codes, tied to conditions visible in the patient, should be used in the annual physical.

Then there is something like Hepatitis C, where blood work is required for an initial diagnosis.  And blood work is required to declare the patient "cured".  At the "cured" stage, there will be no symptoms to use as diagnosis points to support the blood work.  The blood work is actually testing to see that the level of Hep C virus is so low as to be undetectable.  So what DX diagnosis would one use to support the blood test that is looking for no detectable level of the Hep C virus?  I'm guessing that the answer probably varies from Carrier to Carrier.

A possible DX candidate for Hep C and other diseases that might go away with treatment and so you want to verify that it is gone with a blood test is Z86.19 (for an example).  See the following link:

https://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z77-Z99/Z86-/Z86.19

And - see this link where Medicare allows screening test for Hep C, and so maybe there are exceptions such as this one re. screening tests for other diseases that supposedly can be treated out of existance.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9200.pdf

Kerri

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Re: DX for blood tests
« Reply #9 on: March 05, 2021, 10:19:38 AM »
Thank you Richard.  I have copied and printed both of your responses.

Meds are refilled all year thru, but patients HAVE to have a yearly physical to continue their scripts. The mostly generic labs are done to see if anything shows up they don't know about.  We do our own DM testing here in the office (83063, 82044, etc)  Its the CMP, LIPIDS. BMP, etc that are not getting paid with the dx Z13.0

RichardP

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Re: DX for blood tests
« Reply #10 on: March 05, 2021, 03:04:00 PM »
Kerri - you are welcome.

Your comments seem to indicate that there is some butting of heads between you and the providers over how to code for these screenings.

Seems to me the simple solution would be to show the providers the EOBs that are returned showing that the CPT codes linked to the Z13.0 DX code get paid zero dollars.  If the dollars paid are actually something greater than zero, then that is the end of the issue.  But if those dollars paid actually are zero, a demur wouldn't you like to get paid for these screening tests? should trigger some sort of better response in the providers' minds.

Kerri

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Re: DX for blood tests
« Reply #11 on: March 05, 2021, 04:08:02 PM »
sigh, that's part of the problem.  We submit the order, but the labs are done elsewhere. And when the insurance doesn't pay, the patient calls ME saying we coded it wrong. If I say we don't code it, Spectrum does, they say Spectrum said to call YOU.  So we are not billing it out, or getting paid for it. And the hospital doesn't care. I work in a very Liberal office and we go out of our way to help the patients.  I have been here 5 months and this is by far my biggest problem.

RichardP

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Re: DX for blood tests
« Reply #12 on: March 05, 2021, 05:38:08 PM »
These are rhetorical questions.  I'm not expecting an answer, but they might help focus your attention.

1.  Does the lab accept blood for testing without any instructions re. what to test for?

2.  If the answer to #1 is No, (and it should be no), then they are coding based on the information provided by the doctor.  That would be why they say to call you.

3.  Whoever is drawing the blood to send to the lab has to be doing it at the direction of the provider.  What reason did s/he give the blood drawer for why they needed to draw blood and send it to the lab?  Again, the labs aren't going to accept blood for testing without knowing what they are testing for.  So - what the provider tells the drawer of blood would be the place to examine what is going on.  "What they are checking for" would be the CPT code your office must provide.  "Why they are checking for that thing" would be the DX code your office must provide.

The lab should not be making things up out of thin air.  They should be acting based on what your office tells them.  If this is not happening, (if the lab is not getting CPT and DX codes from your office) I would start looking for kickbacks from the lab to your office.  No instructions to the lab would be an indicator of fraud.  (e.g., here, run any test on this and give me part of the money you get for doing this.)

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Re: DX for blood tests
« Reply #12 on: March 05, 2021, 05:38:08 PM »