Wiki Commercial Payors Screening colonoscopy turns diagnostic

[Christyridge76]

Commercial payors - two part question;
1. What turns a screening colonoscopy into a diagnostic: 00812 turns into a 00811?
2. What modifier would be used?

Example: A patient would come in for a screening colonoscopy. They have 3 polyps removed by cold snare. Would it then become a 00811/33orPT or remain a 00812/33orPT?

 

[LisaAlonso23]

For commercial insurance, use 00812-PT when a screening colonoscopy turns diagnostic. Z12.11 will be listed first followed by the finding(s).

Medicare and Medicare Advantage Plans require 00811-PT when a screening colonoscopy turns diagnostic.

Modifier 33 is not used in this scenario for either type of insurance.

 

[ALALA]

I would recommend looking for a Preventative policy for each insurance. It's been my experience that many have their own rules. Example: Cigna requires Z12.11 w/ 00812 even if polyps are found (no PT modifier).

 

[TThivierge]

Hi
What section were the polyps found in? I hope the provider listed where polyps plucked from in the patient s colon. Add that but see dx block of D12 instead of just dx giving claim Z12.11.
Lady T

 

[lschock79]

For ALL commercial policies screening to diagnostic is 00812 with PT. The only time you would use 00811 on a screening turned diagnostic for a commercial payor is if they have a previous history of polyps (z86.010). Currently Aetna, UHC and Cigna are all wanting 00811 NO PT mod with z1211, z86010, but BCBS for example will still take the 00812 PT in this scenario. However @TThivierge is correct in that you should absolutely review each payor's guidelines for specifics on how they want it coded.