Hi, as soon as I saw BCBS with colonoscopy I wanted to provide a little advice from my experience working anesthesia denials. There may be more than to this then just the procedure code and/or
diagnosis code(s). They had very stringent guidelines when anesthesia could be administered for a colonoscopy. I'm not familiar with SC BCBS but with a little digging I believe I located their provider website at:
https://web.southcarolinablues.com/...ter/medicalpoliciesandclinicalguidelines.aspx
Once you are on this page select the hyperlink for medical policies (as I displayed in blue below):
Medical Policies
Read the
medical policies we use to make clinical determinations for a member's coverage.
This opens a new page:
http://www.cam-policies.com/internet/cmpd/cmp/mdclplcy.nsf/DispAlphaList?openform
I then entered "colonoscopy" in the medical policy search box (upper right corner) and found a link for
Anesthesia Services.
Opening this page:
http://www.cam-policies.com/interne...DD6152BF7346756F8525811E006321CA?OpenDocument
I think it would be beneficial to see their guidelines. Scroll about 1/4 of the page down and under heading
Special Procedures - four sentences below this heading it states the following:
"Most routine gastrointestinal endocopic procedures
DO NOT require general anesthesia. Therefore, general anesthesia services are considered not medically necessary. Anesthesia services may be considered
MEDICALLY NECESSARY during gastrointestinal endoscopy, colonoscopy and sigmoidoscopy procedures in any of the following situations:
- Prolonged or therapeutic endoscopic procedure requiring deep sedation
- A patient has a history of or anticipated intolerance to standard sedatives (e.g., patient on chronic narcotics or benzodiazepines, or has a neuropsychiatric disorder)
- A patient who is at increased risk for complication due to severe co-morbidity
- A patient over the age of 70
- Pediatric patients (age 15 and under)
- Patients who are pregnant
- A patient who has a history of drug or alcohol abuse
- Uncooperative or acutely agitated patients (e.g., dementia, organic brain disease, senile dementia)
- A patient who has increased risk for airway obstruction due to anatomic variant including any of the following:
- History of previous problems with anesthesia or sedation
- History of stridor or sleep apnea
- Dysmorphic facial features, such as Pierre-Robin syndrome or trisomy-21
- Presence of oral abnormalities including, but not limited to, a small oral opening (less than 3cm in an adult), high arched palate, macroglossia, tonsillar hypertrophy or a non-visable uvula neck extension, decreased hyoid-ment distance (less than 3cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation or advanced rheumatoid arthritis
- Jaw abnormalities including, but not limited to, micrognathia, retrognathia, trismus or significan malocculusion.
If the Member does not meet the above criteria, there is no anesthesia reimbursement allowed for endoscopic, colonoscopy or sigmoidoscopy procedures."
As I stated when BCBS MN came out with their policy, I was literally faced with hundreds of denials. It took lots of research and time to complete appeals. Unfortunately on those claims I was unable to identify medical necessity; we adjusted the charges off but I felt we were aggressive with our appeals (secondary appeals when necessary) and our hard work paid off to receive reimbursement.
Almost every anesthesia denial utilized the same adjustment codes on the EOB. 1st one listed was N356 (this service is not covered when performed with or subseq...) along with 96 (non covered charge).
It may be worth a direct phone call to SC BCBS to find out exactly why the claim is being denied and receive insight. I wish you lots of luck for resolution on your denials.
Thanks for listening,
Dana Chock, RHIT, CPC, CANPC, CHONC, CPMA, CPB
Coding Analyst (May 2018-present), Anesthesia, Pathology, & Laboratory Coder (Fall 2012 - May 2018), Denial Specialist (December 2012-December 2016)