Wiki Claim denial based on LRC or SI

[patdow]

We billed a colonoscopy claim with ICD 10 K52.9, D12.8, D12.2, and D12.5. The CPT is 45385 and 45380 with modifier 59. We have billed these CPT codes with the modifier several times before and they got paid. Community Health denied this claim. The denial description is Services is not payable based on the LRC; line return code or SI; status indicator generated.

What does this denial mean? I’m unsure what CHC wants me to change.

 

[TThivierge]

Pat
First dx code should be with D12 blocks, then K52.9 colitis , then last dx code Z12.11 or Z13.811, use XS modifier not modifier 59 since it defines differ areas of colon found polyps. The 2 CPT seem in conflict since both biopsy removal. Did you link each dx with proper CPT treatment? Anytime polyp removed put that first on claim, then other dx and Z dx code last. Colitis does not match up to 45380 or 45385 polyp in colon removed.
I hope this data helps you.
Lady T

 

[patdow]

Pat
First dx code should be with D12 blocks, then K52.9 colitis , then last dx code Z12.11 or Z13.811, use XS modifier not modifier 59 since it defines differ areas of colon found polyps. The 2 CPT seem in conflict since both biopsy removal. Did you link each dx with proper CPT treatment? Anytime polyp removed put that first on claim, then other dx and Z dx code last. Colitis does not match up to 45380 or 45385 polyp in colon removed.
I hope this data helps you.
Lady T

Thank you for your response. The patient had a colonoscopy due to chronic diarrhea. It was not a screening. Can you please explain why the D12 blocks should be primary and why we should add Z12.11 or Z13.811? We have never had an issue with using both CPT codes. I have never heard of using Z12.11 last since that is usually the reason for the colonoscopy.

 

[TThivierge]

Thank you for your response. The patient had a colonoscopy due to chronic diarrhea. It was not a screening. Can you please explain why the D12 blocks should be primary and why we should add Z12.11 or Z13.811? We have never had an issue with using both CPT codes. I have never heard of using Z12.11 last since that is usually the reason for the colonoscopy.

If polyps are discovered in the colon which be on lab results and provider should explain this in documentation where pluck bx ...you code them as primary. Then I d use dx Z12.11 cause this is why investigating the colon looking for cancer. If not a polyps use a symptom or definitive dx from documentation
I hope this makes sense
Lady T