Q&A: Conflicts between coding guidelines and payer’s claims processing requirements

Q: I'm told, although I'm not convinced, that our payment for Keytruda is denied by Anthem when we use Z51.11 (encounter for antineoplastic chemotherapy) first followed by the code for cancer, i.e. C34.12 (malignant neoplasm of upper lobe, left bronchus or lung). I reviewed the coding guidelines again and that is our instruction. Does anyone have experience with this issue?

A: The coding guidelines do instruct that Z51.11 should be reported first. However, many payers will require that the codes be listed in a different 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 Local Coverage Determinations. Medicare's claims processing system required a certain order for the diagnosis codes that did not follow coding guidelines. To get the claim to process, providers had to bend to the requirements. 

Editor’s note: This question was posted in the Billing and Claims section of the NAHRI Forums.