Wiki Medicare denial for colonoscopy

[patdow]

Medicare denied claim. ICD 10 codes are Z86.0101 and K64.0. CPT is G0105. Denied because Medicare deemed these are non-covered services because this is not deemed a medical necessity by the payer. Does anyone know what I did wrong?

 

[dkissel]

What is the date of service? If before 10/1/24 use Z86.010 (without the 7th digit) and I would not send with K64.0 as that does not support the scope

 

[patdow]

What is the date of service? If before 10/1/24 use Z86.010 (without the 7th digit) and I would not send with K64.0 as that does not support the scope

DOS is after 10/1/24. So you think it will pay if we only delete the K64.0 code? Hemorrhoids are found in colonoscopies.

 

[TThivierge]

DOS is after 10/1/24. So you think it will pay if we only delete the K64.0 code? Hemorrhoids are found in colonoscopies.

I d put first dx K64, then Z12.11 and Z86.010. K64 is ok rationale for checking see if anything else wrong in near that area. But having Z dx codes first is wrong...reason for denial.ICD10 manual states dx Z86 or Z12 are not first listed x code.
I hope this data helps you
Lady T

 

[amhoward@itbroadcasting.com]

K64.0 with Z86.010 surveillance colonoscopy for a high risk patient (CPT G0105) with personal history of polyps looks fine for Dx. If that doesn't work, it could be something else in CMS guidelines like additional documentation needed from the medical record providing the timing and reason for the follow up colonoscopy. 24 months+ could be covered depending on the documented findings of the previous colonoscopy. Or if there was a current symptom such as blood in stool - triggering the timing of the follow-up test.