By: Tami Shaw, Client Manager, Lighthouse RCM Solutions
Lighthouse billing and coding specialists have recently observed a rising trend of claim denials for laboratory services involving the Z00.00 diagnosis code. This code, which is used for general adult medical examinations without abnormal findings, often needs to be accompanied by additional diagnosis codes to avoid denials.
Check out the fact sheet below for key considerations when billing for claims with a Z00.00 diagnosis (DX) code.
Key points to consider when utilizing Z00.00:
- Primary Diagnosis Requirement: While Z00.00 is typically reported as the primary diagnosis, it should not be the sole code listed. Including other relevant diagnosis codes provides a more comprehensive picture of the patient’s condition.
- Medicare Policies: Medicare has specific guidelines regarding Z-codes. For example, Medicare does not cover laboratory claims if Z00.00 is the only diagnosis code provided, as it is considered a screening code. It’s important to check the Medicare National Coverage Determinations (NCD) for a list of Z-codes that are not covered for laboratory services.
- Payer Preferences: Different payers may have varying requirements for pre-operative and other examinations. For instance, some payers prefer that the condition for which the patient is scheduled for surgery be listed as the primary code, with Z01.818 (Encounter for other preprocedural examination) as a secondary code. Medicare will not pay a laboratory claim if Z00.00 is the only diagnosis code. Refer to the Medicare NCD Coding Policy Manual for a list of non-covered codes: www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDsICD10.html
- Combining Codes: When multiple encounters occur on the same day, and the medical records are combined, certain Z-codes can be reported as the principal diagnosis. This includes codes like Z00.00, Z01, Z02, and others listed in the ICD-10-CM guidelines.
Reducing Z-code denials
To reduce denials, ensure that you are familiar with the specific guidelines and payer policies related to Z-codes. Including additional diagnosis codes can help improve the chances of claim approval. Be aware of codes that should not be used together due to “Excludes 1” and “Excludes 2” conflicts.
Example Conflicts:
Acceptable Principal Diagnosis Z-Codes
Please refer to the below list of acceptable primary ICD-10 codes beginning with “Z”:
- Z00 Encounter for general examination without complaint, suspected or reported diagnosis. (Except: Z00.6 Encounter for examination for normal comparison & control in clinical research program)
- Z01 Encounter for other special examination without complaint, suspected or reported diagnosis
- Z02 Encounter for administrative examination
- Z03 Encounter for medical observation for suspected diseases and conditions ruled out
- Z04 Encounter for examination and observation for other reasons
- Z33.2 Encounter for elective termination of pregnancy
- Z31.81 Encounter for male factor infertility in female patient
- Z31.82 Encounter for Rh incompatibility status
- Z31.83 Encounter for assisted reproductive fertility procedure cycle
- Z31.84 Encounter for fertility preservation procedure
- Z34 Encounter for supervision of normal pregnancy
- Z39 Encounter for maternal postpartum care and examination
- Z38 Liveborn infants according to place of birth and type of delivery
- Z40 Encounter for prophylactic surgery
- Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury
- Z51.0 Encounter for antineoplastic radiation therapy
- Z51.1 Encounter for antineoplastic chemotherapy and immunotherapy
- Z52 Donors of organs and tissues (Except: Z52.9 Donor of unspecified organ or tissue)
- Z76.1 Encounter for health supervision and care of foundling
- Z76.2 Encounter for health supervision and care of other healthy infant and child
- Z99.12 Encounter for respirator [ventilator] dependence during power failure
Communication with Ordering Providers
As a laboratory, you don’t control the diagnosis codes assigned by the ordering provider. This means you must encourage providers to ensure Z00.00 is not the only code used. Including additional diagnosis codes that accurately reflect the patient’s condition can reduce claim denials and align with payer policies and Medicare guidelines.
Clear documentation and coding practices are essential for smoother claim processing. If you’re seeking coding guidance or have other questions, feel free to contact our team for a complimentary consultation!