Diagnoses Codes

40.4 - Diagnoses Codes (Rev. 11445, Issued:06-03-22 Effective:05-09-22, Implmentation:05-09-22) Below are the current diagnoses that should be used when billing for screening pelvic examination services. Effective Oct 1, 2015 the following chart lists for the ICD-10-CM codes that CWF must recognize for low risk or high-risk patients for screening pelvic examination services. Low Risk Diagnosis Codes ICD-10-CM codes Description Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings Z12.4 Encounter for screening for malignant neoplasm of cervix Z12.72 Encounter for screening for malignant neoplasm of vagina Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs Z12.89 Encounter for screening for malignant neoplasm of other sites High Risk Diagnosis Codes ICD-10-CM codes Description Z77.9 Other contact with and (suspected) exposures hazardous to health Z77.29 Contact with and (suspected) exposure to other hazardous substances ICD-10-CM codes Description Z72.51 High risk heterosexual behavior Z72.52 High risk homosexual behavior Z72.53 High risk bisexual behavior Z91.89 Other specified personal risk factors, not elsewhere classified Z92.850 Personal history of Chimeric Antigen Receptor T-cell therapy Z92.858 Personal history of other cellular therapy Z92.86 Personal history of gene therapy Z92.89 Personal history of other medical treatment A. Applicable Diagnoses for Billing an A/B MAC (B) For professional claims, providers report diagnosis codes according to the instructions in the ASC X12 837 professional claim technical report 3 for electronic claims and chapter 26 of this manual for paper claims. Part of this reporting includes pointing (relating) the claimed service to a diagnosis code on the claim. There are a number of appropriate diagnosis codes that can be used in billing for screening pelvic examinations that the provider can list on the claim to give a true picture of the patient’s condition. In addition, one of the diagnoses listed in either the high risk or low risk tables above (§40.4) must be on the claim to indicate either low risk or high risk depending on the patient’s condition, and the screening pelvic examination service must point to this diagnosis code. Providers must make sure that, for screening pelvic exams for a high risk beneficiary, a high risk diagnosis code appears on the claim and that the screening pelvic examination service points to this diagnosis code. If pelvic examination claims do not point to one of these specific diagnoses, the claim will reject in the CWF. If these pointers are not present on claims submitted to A/B MACs (B), CWF will reject the record. Periodically, A/B MACs (B) should do provider education on diagnosis coding of screening pelvic examination claims. B. Applicable Diagnoses for Billing an A/B MAC (A) For institutional claims, providers report diagnosis codes according to the instructions in the ASC X12 837 institutional claim technical report 3 for electronic claims and chapter 25 of this manual for paper claims. (Chapter 25 also contains additional general billing information for institutional claims.) Appropriate diagnoses are shown above in this section for low risk and high risk beneficiaries. Periodically provider education should be done on diagnosis coding of screening pelvic exam claims.