High Risk Colonoscopy

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sherryo35

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Please help. Is anyone else seeing denials for medical neccesity from Medicare when billing G0105 with dx V12.72? this just started for us in July and am getting no good direction with Medicare.
 
We received a denial for the same reason today. Where is your practice, we are in NC. Palmetto referred us to the NCD, however, they stated that the NCD has not been updated on the CMS website, but that it was effective 7/1/14. I am still researching, there is absolutely nothing on the CMS website. I am wondering if they are going to move hx of colon polyps and family hx to the low risk category.

Colorectal Cancer Screening Tests
NCD 210.3
IOM Publication 100-03 Medicare National Coverage Determinations, Chapter 1, Section 210.3
NCD Original Effective Date: 01/01/2004
CPT/HCPCS Codes
CPT Code Description
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema


ICD-9 Code(s) that Support Medical Necessity
Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this NCD have been met.

Partial List of ICD-9-CM Codes Indicating High Risk: Only applicable to G0105 and G0120 (high risk colorectal screening)

Code Description
555.0 Regional enteritis of small intestine
555.1 Regional enteritis of large intestine
555.2 Regional enteritis of small intestine with large intestine
555.9 Regional enteritis of unspecified site
556.0 Ulcerative (chronic) enterocolitis
556.1 Ulcerative (chronic) ileocolitis
556.2 Ulcerative (chronic) proctitis
556.3 Ulcerative (chronic) proctosigmoiditis
556.8 Other ulcerative colitis
556.9 Ulcerative colitis, unspecified
558.2 Toxic gastroenteritis and colitis
558.9 Other and unspecified noninfectious gastroenteritis and colitis
V10.05 Personal history of malignant neoplasm of large intestine
V10.06 Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
 
cpoeward thanks for tour reply. We are in SC, so we are in the same jurisdiction. I was beginning to think we were the only ones having this issue. I sent you a private message on here discussing steps i have taken to try to get resolution. Please keep me updated with your progress as i will you also.

Thanks,
 
ugh

I'm in NC too and having the same luck as everyone else finding anything about this new policy from 7/1/14 except for what Palmetto has. Can't find a thing about it and I've been researching online for 3 days here and there. Nothing in any MLN Matters about this change, nothing on the CMS.gov website.

The AGA has not put out anything either.

Very frustrating.
 
I have found a MLN #8691 that references this NCD that became efffective 7/1/14. THis has to be related, but my understanding of the memo is that the changes were only to enable their system to accept icd-9 or icd-10 codes. It states that no POLICY changes were made. I think this is a Medicare System issue, but cant get anyone at medicare to see that... I have emailed the Medical Director but have not received a response. I have also exculated one of our claims to a manager. We have appealed one claim. But this is much bigger than a claims denial issue. Please let me know if you have any updates and i will you as well.
 
This is a posting that was in ASCA Connect the by boss forwarded to me. We haven't run into this issue... yet... at our facility. but it seems that a lot of people are having issues.

Subject: RE: Palmetto GBA Denying G0105 with V12.72




Thanks, Beth! That's what we started doing, but we never had to before. These cases are considered surveillances not true screenings and according to the AAPC literature and the ASC Winter Coding conference you drop the V76.51. However, I do realize that we need to code according to payer protocol. I just think it odd that they just started rejecting after all this time...
-------------------------------------------
Dawn Langness CPC-H
AR/Coder
Outpatient Surgery Center of Hilton Head
Hilton Head Island SC
843.682.5004
-------------------------------------------

-------------------------------------------
Original Message:
Sent: 07-22-2014 09:25
From: Beth Hamilton
Subject: Palmetto GBA Denying G0105 with V12.72


Have you tried coding V76.51 first, to indicate the screening, then V12.72 to indicate high risk?
-------------------------------------------
Beth Hamilton CPC CASCC
Coder
Twin Cities Surgery Center
Festus MO
636.931.5997
-------------------------------------------

-------------------------------------------
Original Message:
Sent: 07-21-2014 10:54
From: Dawn Langness
Subject: Palmetto GBA Denying G0105 with V12.72

Has anyone else been receiving denials for listing ICD9 V12.72, History of Polyps for a high risk screening? Two calls to Palmetto GBA has received the same response that NCD 210.3 was just updated and that the V12.72 is no longer acceptable to code with G0105. I searched and can't find any such update. Also, since G0105 is listed on the ASC-10 Quality Report for diagnosis V12.72, V13.89, and V10.05 I would think that CMS would have sent an update for that reporting, too.

Thanks,

-------------------------------------------
Dawn Langness CPC-H
AR/Coder
Outpatient Surgery Center of Hilton Head
Hilton Head Island SC
843.682.5004
-------------------------------------------

 
Thanks for the info. This seems to be only affecting Jurisdiction 11 (J11)- Palmetto GBA- North Carolina, South Carolina, Virginia, West Virginia.

Still getting no where on my end, waiting to hear back from provider services and the Palmetto GBA medical director.


Thanks,
 
One of our patients called Medicare and was told there are no changes to the coverage for high risk colonoscopies.

I am reaching out to CMS for clarification. Their address is below for anyone else who wants to contact them

CMS, Atlanta Regional Office
Information on local seminars and health fairs on Medicare health plan choices, or to report a complaint directly to CMS[/B].
Areas Covered: AL, FL, GA, KY, MS, NC, SC, TN
Regions: IV

Address:
61 Forsyth Street, SW, Suite 4T20
Atlanta, GA 30303
 
It turns out Palmetto is using a "Draft" of NCD 210.3 that has an effective date of 10/1/2015.

Like you had said, they are using the icd-9 to icd-10 conversion policy which is not complete on the "draft" obviously.

We're going to start going through the appeals process tomorrow so I'll keep you updated the best I can.
 
Update from Palmetto GBA

Colorectal Cancer Screening
Palmetto GBA is aware that providers are receiving denials on HCPCS codes G0105 and G0120 when billed with previously covered ICD-9 codes. Palmetto GBA is researching the issue with CMS.

Applies to:
Jurisdiction 11 Part B//General
Jurisdiction 11 Part B//Physician
Jurisdiction 11 Part B//Primary Care
Jurisdiction 11 Part B//Surgery
Railroad Medicare (RRB)//General - Railroad Medicare
Railroad Medicare (RRB)//Physician
Railroad Medicare (RRB)//Primary Care
Railroad Medicare (RRB)//Surgery
 
Update

New information from Palmetto

Applies to:
Jurisdiction 11 Part B//General
-------------------------------------------------------------------------

Colorectal Cancer Screening

Palmetto GBA is aware that providers are receiving denials on HCPCS codes
G0105 and G0120 when billed with previously covered ICD-9 codes. Palmetto
GBA is researching the issue with CMS.

http://www.palmettogba.com/palmetto...ce=J11BL&utm_campaign=J11BLs&utm_medium=email
 
Jurisdiction 11 Part Bcpitool
Colorectal Cancer Screening

Issue:
Palmetto GBA is aware that providers are receiving denials on HCPCS codes G0105 and G0120 when billed with previously covered ICD-9 codes. Palmetto GBA is researching the issue with CMS.

Provider Action:
Palmetto GBA will notify CMS about this issue.

Status:
8/12/2014 - Please monitor this CPIL for updates.




last updated on 08/12/2014
 
Is anyone appealing these? Just wondering if we need to sit on these charges and wait to see if Palmetto will adjust, or if we should appeal them. Anyone getting paid for these?
 
RE: G0105 denials w/V12.72

I've just recently ran into the same problem with G0105 & V12.72. Although I'm in Kansas. After reading the article in this months AAPC Healthcare Bus. Monthly it was brought to my attention that I should've been using the PT modifier not just with V76.51 but also w/V12.72, V10.05 & V16.0 when billing Medicare. I'd never thought of them as "screenings". Nor did I think to use a PT modifier when billing BCBS. Although I don't know if that is correct coding or if it's just sneaking by their edits. I am however puzzled that many of you are using V76.51 w/V12.72. Since the ACA we've heard more from patients regarding how their procedure should've been coded. I too have done alot of homework, reading the U.S.Preventative Services Task Force and receiving information for patients. It's mind boggling & frustrating for everyone. In regards to USPSTF statement, "When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for a screening are no longer applicable." The following ICD-9 guideline supports this statement. Please let me know if I'm misunderstanding the guideline. You know how the saying goes, "you have a room full of coders and they'll all have a different opinion".

As per the Official ICD-9-CM Guidelines for Coding and Reporting, Chapter 18, Paragraph D. Categories of V Codes, Section 4, History (of), see below, these two codes cannot be reported together.

There are two types of history ?V? codes, personal and family. Personal history codes explain a patient?s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease. The exceptions to this general rule are category V14, personal history of allergy to medicinal agents and subcategory v15.0, Allergy, other than to medicinal agents. (etc?)

Family history codes are for use when a patient has a family member(s)who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.

Personal history codes may be used in conjunction with follow-up codes. Family history codes may be used in conjunction with screening codes to explain the need for a test or procedure. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.

I take this to mean that you CANNOT code V76.51, screening with V12.72, V10.05, personal history together. But you CAN code V76.51 with V16.0, family history, together. Am I wrong????
 
Update High Risk Screening

On 8/27/14 Palmetto issued a Local Coverage Article (A53573) that was effective on 8/4/14 with the coverage limited to the ICD codes previously listed. During today's Palmetto webcast, I submitted a question whether they are going to pay claims prior to 8/4/14 and was told that they have no plans to reprocess those claims. They directed me the CPIL, which contains no updates. They have also not issued updates concerning the Local Coverage Article in the Medicare Advisory Bulletin. They stated they are still "awaiting further clarification from CMS."

My queries to CMS have gone unanswered.
 
Coachlang3,
What did you base your appeals on? My facility is having the same problems. Have you had respnse to your appeals?
 
Our billers/collectors have not refiled or appealed as I thought they were. They were told by Palmetto to just keep checking the website to see when the issue was fixed.
 
Update High Risk Screening

We heard from Palmetto this morning, they are going to retroactively reprocess the colonoscopies that were previously denied.

Effective 10/11/14 Palmetto has issued a new LCA A53573 (NC) that will cover G0105 for :

V12.72 PERSONAL HISTORY OF COLONIC POLYPS
V16.0 FAMILY HISTORY OF MALIGNANT NEOPLASM OF GASTROINTESTINAL TRACT
V18.51 FAMILY HISTORY, COLONIC POLYPS
 
update:
Status:
Update 9/30/2014 - The processing system will be updated for HCPCS codes G0105 and G0120 to be allowed when ICD-9 codes V12.72, V160 & V18.51 are billed. This update will be retroactive to dates of service July 1, 2014.

Once the system has been updated a mass adjustment will be completed. There is currently no estimated date when this update will be completed
 
High Risk Screenings

Hi List,

I am in Ohio and we are getting these denials as well but for Medicare Advantage plans and with local Medicaid products. They are stating they need the LCD/NCD number 210.3 on the claim as directed by CMS. No where on CMS website for the Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy LCD/NCD does it state that number is required. The payer also could not tell me where on the claim form they want it. The Ohio LCD has not been updated stating we cannot code V12.72 with G0105. The physician representatives are no help since they do not know what to tell us other than what the denial is.

Has anyone had any more updates for this issue?

Thanks, Robin
 
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