Outpatient Chemotherapy Coding Based Denials

nameher

I'm told, although I'm not convinced, that our payment for Keytruda is denied by Anthem when we use the Admission for Chemotherapy code Z51.11 first followed by the coder for cancer, i.e. C34.12.  I reviewed the coding guidelines again and that is our instruction.  Does anyone have experience with this issue?

dwilliamsrsi

The coding guidelines do instruct that Z51.11 should be reported first. However, many payers will have a different order of diagnoses that they require in order to reimburse a claim.  It causes heartburn from a coding standpoint, but look at it as a claims processing requirement.  It doesn't negate the coding guidelines, but in order for the payer to reimburse for the service, their claims processing system requires the codes in a specific order.  We saw this several years ago with some of the LCDs - Medicare's claims processing system required a certain order for the diagnosis codes that did not follow coding guidelines. But in order to get the claim to process, providers had to bend to the requirements.