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DX for blood tests

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Kerri:
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:
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?

Kerri:
Yes, I am, but these are not pre proceedural exams.  These are yearly physicals

RichardP:
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:
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.

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