New Z-Code Requirement from Leading Health Insurer

UnitedHealthcare (UHC) has postponed its Z-code requirement for certain molecular tests from August 1 to October 1, granting labs an additional two months to adjust since its announcement on May 1.

The upcoming UHC mandate will include 136 Current Procedural Terminology (CPT) codes and 106 proprietary lab analysis (PLA) codes in its initial phase. The next year might see the inclusion of specific PCR-based microbiology test claims.

Derived from Palmetto GBA’s DEX registry, Z-codes are unique identifiers for molecular diagnostic tests. Supplanting the former test IDs from United’s Genetic Test Registry, UHC’s new directive demands these codes on insurance claims. The aim? Streamline the claims process, reduce clinical information requests, and enhance reimbursement accuracy.

The policy’s initial focus covers selected molecular diagnostic tests, including those for the Medicare demographic, prenatal screenings, genetic disease carrier evaluations, and pharmacogenomics tests.

While Medicare’s MolDx program and United’s Medicare Advantage plans already utilize Z-codes, the new directive will universalize the Z-code requirement across all UHC plans.

For laboratories, implications differ. Labs in regions with an existing Medicare Administrative Contractor Z-code mandate might need mere system updates. In contrast, other labs face a more intricate journey, securing Z-codes and supplying relevant technical data, potentially taking several months.

Securing a Z-code isn’t swift. Initial evaluations last two weeks, while comprehensive ones can take two months, potentially clashing with timely filing standards.

There’s also ambiguity around the policy’s scope. If UHC introduces a complete technical assessment process, labs could grapple with increased complexities and costs. However, the Z-code stipulation could promote clarity in claims and potentially heighten reimbursement accuracy.

Labs are advised to stay abreast of changes, strategize, and obtain necessary guidance. The delay provides a buffer for labs to smoothly transition to this new era. With foresight, they can adeptly maneuver this change, aiming for elevated efficiency and outcomes.

REFERENCES

  1. United Healthcare. 07.20.2023. https://www.uhcprovider.com/en/resource-library/news/2023/expanded-dex-z-codes-molecular-tests.html#:~:text=In%20order%20to%20ensure%20laboratories,starting%20Oct.%201%2C%202023.
  2. 360Dx. 07.13.2023. https://www.360dx.com/clinical-lab-management/labs-mdx-developers-brace-requirement-united-healthcare-z-codes