Coding > Coding

DX for blood tests

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Michele:
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?

kristin:
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:

--- Quote from: kristin on March 05, 2021, 02:13:32 AM ---Some insurances just will not pay for screening dx's ...
--- End quote ---

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:

--- Quote from: Kerri on March 04, 2021, 06:07:58 PM ---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.

--- End quote ---

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:
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

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