CMS ICD10 High Risk Colons Deny

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CMS provider rep confirmed this past Friday that the high risk screening colonoscopy due to personal history of polyps will deny for "not medically necessary" (G0105 Z86.010).

Per the rep, we are coding it correctly, but CMS will not release these claims for payment until AFTER 1/4/2016. Per the rep, she recommends we hold off billing any high risk screenings until after this date.

She did not state the reason, however, it seems pretty clear that the clinical editing database was not accurately or completely updated with the ICD10 code set.

Side note: It appears as if the commercial Medicare products are managing the above scenario and paying the claims.
 

navila0508

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We just received the same denial. Thank you so much for posting this. They didn't mention anything you stated and left us in the dark. Thank goodness for AAPC forums.:D:eek:
 

lynnmunoz

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Here is the response that I have received from CMS on this very same issue;

"CMS has identified an issue related to some isolated local interpretation of the NCD for colorectal cancer screening, specifically the coverage of high risk screening colonoscopy. CMS is in action to clarify for local contractors the covered codes and you may work directly with your MAC on next steps for your denied claims. We anticipate our clarification will be available for the MACs in the next week.

ICD-10 Coordination Center"
 
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Thanks for sharing. Interesting. I'm in Michigan, curious what state others are in that are getting this denial. Again, CMS assured us an easy transition and if their contractors did not implement the full scope of ICD10, then CMS is ultimately responsible. They were supposed to complete end to end testing, etc.

Hopefully, they'll get the fix implemented prior to January per the memo ....
 

AthensCoder

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Colon Screen

I'm here in Georgia, and today & rep from Cahaba advised the same & also advised to submit an appeal.
 
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UPDATE FROM THE AGA:
Late last week, AGA received reports that some Medicare contractors are rejecting a specific colonoscopy screening code: G0105 with Z86.010. On Monday, AGA, ASGE and ACG met with Sean Cavanaugh, the deputy administrator and director of CMS, and alerted him to this issue.

The affected code is G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) when submitted with ICD-10 code Z86.010 (Personal history of colonic polyps). The problem has impacted beneficiaries in the following Medicare Administrative Contractors (MACs): National Government Services Inc., Novitas Solutions Inc., Noridian Healthcare Solutions, LLC, Palmetto GBA, and First Coast Service Options, Inc.

We have also contacted the CMS Ombudsman, which is investigating the matter. We will continue to work with CMS until a solution is implemented.

Have you received denials for G0105 with Z86.010? Are you experiencing other ICD-10 implementation issues? Please contact Leslie Narramore, director of reimbursement, AGA Institute.
 

Coleene

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CMS ICD 10 High Risk Colon

We are in Mississippi and have received the same denials. We spoke with a rep at Novitas and was told the same thing. She said it was because the ICD10 codes had not been connected to the G0105. She recommended that we submit our claims and call them after January 4, 2016. At least these would show as timely filing. We are doing that and keeping a list of those claims.:)
 

CELADYBUG13

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The following was from CMS in the Daily Newsletter dated 11/03/2015:


Colorectal Cancer Screening Claims Processing Issue
Due to an increase in inappropriate denials, CMS has expedited an update to National Coverage Determination (NCD) 210.3, Colorectal Cancer Screening Tests. CMS is taking action to correct inappropriate denials of HCPCS code G0105 with ICD-10 code Z86.010 where they exist, and appropriate payment will be made for these procedures within 45 days. No action is needed by providers. Please share with appropriate staff.



Applies to:
JM Part A//General
JM Part B//General
Railroad Medicare (RRB)//General - Railroad Medicare
 
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