Wiki Denial on colonoscopy

[patdow]

Question on what needs to be updated after receiving denial for colonoscopy.

Colonoscopy with EGD was performed. ICD 10 codes used were Z12.11, D12.4, D12.2, I85.00, K31.89.

First CPT 45385 with Z12.11, D12.4, D12.2.
Second CPT 45380 and modifier 59 with Z12.11, D12.4, D12.2.
Third CPT 43235 with I85.00, K31.89.

Insurance is community health choice. Denial for 45380. Service is not payable based on the LRC; line return code or SI; status indicator generated.

Billing manager wants to know if we can change Z12.11 to Z86.0100. However, I don’t see that pt has had colon polyps after receiving colonoscopy reports.

 

[Dipstyck]

Hi,
Any diagnosis that a patient has will go on their record. If the patient does not have polyps, you cannot code that. It must match the documentation submitted,
Also, when billing a colon and EGD, you should have modifier 51 on the lowest amount billed as a reduced service.

 

[cmk112@gmail.com]

It has been a while since I coded these procedures, but I believe your primary diagnosis code for each code changes based on what was performed for that CPT. Ie. If it was a regular colonoscopy, it would have been billed as 45378 with the Z12.11. However, the provider found polyps that needed to be removed, and now the screening has turned into therapeutic procedures. I believe the dx's change. I think you should add the appropriate D code for the procedure used to remove it. Ie, the provider performed the 45385 to remove the D12.4 Descending Polyp, and performed a D12.22 to remove the ascending polyp. I would report the following coding for billing: 45385-33/PT with D12.4, Z12.11. (Typically, 33 is used for non-Medicare claims, but I have seen some payers also use PT instead of 33. This modifier indicates that this was meant to be a preventive procedure that turned into a therapeutic one.) I would bill the other code as 45380-33/PT, XS/59, 51 with diagnosis D12.22 and Z12.11. I would add the 59 or XS on the second code, like you did, to indicate to the payer that this procedure was done in a different part of the colon. I agree with the poster above to add the 51 as it is correct coding. I believe the 51 is not needed for Medicare claims, but for other payers, it is.

Please note, it still may not pay depending on the payer rules and contract with the provider, but at least you will set your billing/follow-up team for an appeal if you choose to go that route.

Hope that helps.

Full disclosure, I haven't coded surgeries in a couple of years, and have been doing facility ED encounters for the last 3 years. I may be a bit rusty, or things could have changed. Best of Luck!