Colonoscopy billing

sanag

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Hello,
We are experiencing a high volume of denials for our provider when billing 45380 & 45385 together. I am currently using modifier XS as well.
Typically, we appeal these services, and denials are overturned & appeals are paid. Our appeals outline that the provider is accessing either different points of the colon (ascending colon, cecum, etc.) and/or is using different techniques to perform the procedures (hot snare, cold forceps, etc.).
With the number of denials increasing, I am wondering if there is something that could be done when billing to avoid these denials.
Is anyone else experiencing this type of denial that could assist?

Thank you in advance!
 

TThivierge

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Hi Sanag,:)

What is your primary dx code? Are you using the dx which signifying which part of colon the polyp came from dx D12 blocks? Or just using K63 dx? Or using a Z code for first dx code?
if read descriptions CPT 45380 is biopsy single or multiple polyps then read CPT 45385 with removal of tumors....it may sound repetitious from the payer s view,but differ removal process. I say add modifier 51 on it since more than once of differ polyps and multiple procedure. Keep XS modifier show differ areas of polyps when pulled from intestines. Is this a Medicare pt in which use G codes and modifier 33 for if a screening.

I hope helped a little bit

Lady T:)
 
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sanag

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Hi Lady T,
Thank you for your review and response.
Billing example of current billing-
Biopsy was taken from the cecum and polypectomy from the sigmoid colon.
45385 (DX K63.5)
45380-XS (DX- K63.5)

If I am understanding your suggestion correctly, you are suggesting we bill something like below-
same context-Biopsy was taken from the cecum and polypectomy from the sigmoid colon
45385 (DX -D12.5)
45380-xs,51 (DX- D12.0)

Thank you again for your assistance!
 

TThivierge

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Hi Sanag
One more thing ..if the doctor mention the patient had colonoscopy like years ago add dx Z86.010 i& f polyps were discovered or add dx Z83.71 dx code if runs in their family as the last dx or Z12.11 as encounter check for colon ds as last dx code. I is alwyas nice to end with Z dx code for more detail on claim if related to main problem.
I am glad I could help you
Lady T
 
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