Many healthcare providers face confusion when it comes to selecting the correct primary diagnosis code for screening colonoscopies, especially in patients with a personal history of colonic polyps. A common question arises: Can Z86.010, representing a personal history of colonic polyps, be a primary diagnosis? This article addresses this question, drawing from ICD-10-CM guidelines to provide clarity and ensure accurate medical coding for optimal claim processing.
Let’s consider a scenario where a patient with a history of colon polyps undergoes a colonoscopy. A previous colonoscopy, performed two years prior, and the current one both yielded no findings of polyps. If the procedure is billed using Z86.010 (Personal history of colonic polyps) along with G0105 (Colorectal cancer screening; colonoscopy on individual at high risk), it’s possible to encounter claim denials citing “ICD-10 is an unacceptable principal diagnosis.” This was the exact situation described by a participant in the AAPC Forum seeking clarification on their coding approach.
The reason behind such denials lies in the ICD-10-CM official guidelines. Specifically, guideline I.C.21.c.4, which pertains to personal history codes, clearly states that “the reason for the encounter (e.g., screening or counseling) should be sequenced first.” Subsequently, any relevant personal and/or family history codes should be assigned as secondary, or additional, diagnoses. Therefore, relying solely on Z86.010 as the primary diagnosis in the aforementioned scenario is not compliant with ICD-10-CM guidelines.
In cases like this, where a screening colonoscopy is performed on an individual at high risk due to a personal history of colon polyps, the appropriate primary diagnosis should reflect the encounter’s purpose – the follow-up examination. A suitable code to use as the first-listed diagnosis is Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm).
Within the ICD-10-CM codebook, under code Z09, there’s a crucial “Use additional code” instruction. This instruction directs coders to include codes from category Z86 (Personal history of certain other diseases) and Z87 (Personal history of other diseases and conditions) to provide further context. Reinforcing this guideline, both the Z86 and Z87 code groups include a “Code first any follow-up examination after treatment with Z09” instruction.
Therefore, to correctly code the colonoscopy in our initial scenario, the sequence should be:
- Primary Diagnosis: Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm)
- Secondary Diagnosis: Z86.010 (Personal history of colonic polyps)
- Procedure Code: G0105 (Colorectal cancer screening; colonoscopy on individual at high risk)
By adhering to these ICD-10-CM guidelines and correctly sequencing the diagnosis codes, healthcare providers can avoid claim denials and ensure accurate representation of the patient’s encounter. Understanding the nuances of primary and secondary diagnosis coding is essential for efficient and compliant medical billing practices.
