Wiki Anesthesia for Endoscopy

[commitsvs]

Hello Everyone,
I need some clarification on Anesthesia for Endoscopy with AA, QS, P2 or P3 Modifier and some insurance like
1. BCBS Nj for CPT 00731 is getting denied as (Benefit for service included in payment for another service like Colonoscopy and Endoscopy that was adjudicate) were we have billed E11.9 as Primary DX and K21.00 as Second DX.
2. UHC for CPT 00731 is getting denied as (Non-covered services - not deemed 'medical necessity' by the payer) were we have billed K21.00 as PDX.
3. BCBS Nj for CPT 00812 is getting denied as (Benefit for service included in payment for another service like Colonoscopy and Endoscopy that was adjudicate) or (incidental to primary CPT 45378) were we have add Z12.11 as PDX.
BCBS Nj for CPT 00812 is getting denied as (Benefit for service included in payment for another service like Colonoscopy and Endoscopy that was adjudicate) or (incidental to primary CPT 45378) were we have add E11.9 as PDX

Kindly let me what to do for this scenario and solution

 

[LisaAlonso23]

First question: Are you coding/billing for an anesthesiologist or CRNA? My responses below are according to how you posed your questions.

1. Was the EGD performed with a colonoscopy? Also, first diagnosis is diabetes which would not prove medical necessity for an EGD. The first diagnosis should be the reason the EGD was performed (ie, K21.00), and the co-morbidity diagnosis should follow.

2. There's not enough information to state why 00731 K21.00 was denied. It may be helpful to add a co-morbidity diagnosis to justify the anesthesia.

3. There's not enough information to state why 00812 was denied with Z12.11. Where there findings? Was a procedure performed during the colonoscopy (ie, polyp removal, biopsy, etc.) or was this performed along with an EGD? Again, E11.9 is the code for Diabetes that would not prove medical necessity for 45378 (colonoscopy).

 

[commitsvs]

Hello Lisa,

Thank you for your response,

We are coding/billing for an anesthesiologist.

1. Yes, first diagnosis is diabetes which would not prove medical necessity for an EGD, but we got denial's after adding K21.00 as medical not necessity and some like it already included in procedure.
so, after reviewing we found that we need to add Co morbidity diagnosis to justify the anesthesia as below mentioned example and then later we changed primary ICD to E11.9 we got some payment, but few claims got denied.

2. Adding co morbidity as a secondary ICD was an attempt, but it was still denied.

3. Most of the denials was colonoscopy or EGD very few where both procedures performed during the colonoscopy along with an EGD.

4. Majorly we are getting denied from BCBS NJ (This is included in procedure) Denial Code CO 97 and Rep stated that the claim denied as included with CPT 43239 that was performed on the same day, The CPT code 00731 is denied as this service is incidental to procedure (43239) code already paid for the same DOS, claim denied as CPT 00731 inclusive with the CPT 43239 and THIS SERVICE IS NOT PAID SEPARATELY


I am hopeful that the information is adequate for review.