CAP Has “Serious Concerns” with UnitedHealthcare’s Z-Code Rollout

by | Jul 19, 2023 | College of American Pathologists, Z-Codes | 0 comments

The College of American Pathologists (CAP) has sent a letter to Optum requesting a meeting to discuss its partnership with Palmetto GBA and UnitedHealthcare’s new Z-code requirement. CAP and Optum are in the process of scheduling the meeting, says Jonathan Myles, MD,
Chair of CAP’s Council on Government and Professional Affairs.

Myles notes that HIPAA designated AMA CPT as the official code set for use in claims, and CAP made the argument back when the Z-codes first started that it violated HIPAA to require the use of an alternative code set. Only CMS (HCPCS level II codes) or the AMA (CPT codes) may develop code sets for laboratory services under HIPAA. If a provider desires to file an electronic
health care claim, a health plan must accept such a transaction that is filed in HIPAA standard format. Furthermore, only HIPAA-approved code sets may be required by a plan in connection with electronic health care claims, adds Myles.

Myles maintains that the existing CPT Editorial Panel has the infrastructure and capacity to process code requests on a quarterly basis, provide transparency and offer a public forum at regular intervals several times a year. This process would be the appropriate method for insurers to address any issues with information on specific tests without adding further requirements and reporting complexity.

CAP has requested that Optum and UHC remove Z-code requirements.