Wiki medicare denying code Z12.11

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christy.brown@kdmc.net

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Pt comes in for a screening colonoscopy. During colonoscopy dr finds polyps. They are removed with snare 45385-PT or forcepts 45380-PT. I am billing Z12.11 as primary as pt was here for a screeing and then code for polyps. Medicare is denying all of these claims stating non covered not deemed med necessity. We have never had this issue before. I am getting no where on this with Medicare. Is anyone else seeing this issue?
Thank you!!!
 
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You code the screening Z code first and the polyp second. This must be an issue with the edit system. It seems I remember someone stating they had to hold them until after the 4th of January. But you did code it correct
 
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I saw the post about the high risk G0105 with Z86.010. We are also having that issue too. But this is just the regular screening Z12.11 that is now denying. and medicare is no help.
 
denying all claims with 45385-PT and 45380-PT with code z12.11 then codes for polyps as not med necessity. But this is a new issue. Our claims never denied for this before. And it is just Medicare denying them.
 
christy.brown@kdmc.net said:
denying all claims with 45385-PT and 45380-PT with code z12.11 then codes for polyps as not med necessity. But this is a new issue. Our claims never denied for this before. And it is just Medicare denying them.
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Is the denial co-50? If not, what is it? Also, what diagnosis/diagnoses were the line items pointing to?
 
christy.brown@kdmc.net said:
yes denial is a co-50 non cvd,not deemed a medical necessity. I have the 45385-PT with the primary dx as Z12.11 as was a screening colonoscopy then codes D12.5 and
D12.3.
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I wonder if the patient had a screening within the last 10 years and it can't be a screening. I think you should call Medicare and ask about this, but the only thing I can think of is the screening was too soon and if you billed it and pointed to the polyp they would pay it as a diagnostic colonoscopy.

I have not ever run into this situation before. Please let us know what Medicare tells you!
 
in my area Medicare will deny if we don't change the diagnosis pointers on a screening that had something removed or biopsied. list first the screening dx and then when you send the claim you need to change the dx pointers to b and then a instead of a and then b.
 
We are seeing this denial also. The problem started with ICD 10. Medicare has always allowed CPT 45380 with ICD 9 V76.51 (screening for malignant neoplasm, colon) as screening, but now when we're using the same diagnosis code in ICD 10, Z12.11, they're denying it for routine. I think they have a system issue with their claim edits. So far I've been unable to get Medicare to understand the problem.
 
I have posted this before but in my area Medicare says you have to reverse the dx pointers on the claim when it is screening turned diagnostic. so the primary dx would still be Z12.11 followed by your polyp code but the diagnosis pointers on the claim need to be the opposite.. The first position pointer needs to point to the polyp code and the second the Z code. If you don't know how to bill the claim and change the dx pointers before it goes out in your system contact your billers and ask them.
 
You can only use Z codes with the G0121 or G0105. If biopsies are done, you have to use the polyp codes instead. Just add the PT modifier to your CPT code and they'll pay just fine.
 
I agree with Debra that you are coding these absolutely correctly and the NCD for colonoscopies does list Z12.11 to support medical necessity. This has to be an issue with the editing system and I would send a reconsideration request. While it is possible that the frequency has been exceeded, I would not expect a CO-50 denial for that. I suggest you escalate your inquiry.

Karen
 
I know Medicare was having an issue with an LCD(benign skin neoplasm), that was causing other CPT codes not related to the LCD to deny as non-medically necessary CO-50. This is a problem at Medicare and they have been working on it and hopefully have it resolved. They supposedly will reprocess all claims. We noticed it beginning on our 1/7/16 remits.
 
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