Wiki Hx of Polyps

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I'm in Michigan and billing Blue Cross for patient's having a hx of polyps. I am using the new diagnosis codes and am getting rejected stating its not a benefit when you perform it for the reported dx. Michigan Blue Cross and Blue Care Network are rejecting claims for these new codes.
Is anyone else having trouble?
 
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Encounter
Are you using secondary Z dx as first dx on claim? If so that will cause a denial. Put a dx of symptoms or digestive problem first dx then use Z13.820 or Z12.11 or Z86.010 as last dx. Follow provider documentation on patient s problem first.
I hope helped you
Lady T
 
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These patient's are only coming in because they have a history of colon polyps (tubular adenomas) They had a colon say 3-5 years ago and polyps were found and now they're back due to increased risk for colon ca. The report finds nothing on the current procedure and they have no other issues. I used the new icd10 code Z86.0101. This is saying that these patient's that are high risk for colon cancer, BX won't pay for their colonoscopy? only 1 every 10 years? Something doesn't seem right
 
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I am sort of having this same issue. I was always under the understanding 1 every 10 years was for Medicare. Was just about to come here and ask if anyone knew or thought of it billing as dx of polyp primary and Z86.010 secondary with modifier 33 on procedure code?
 
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Needing clrification on patients with a hx of colon polyps. Currently we are billing surveillance colonoscopy with G0105 with Z86.0100, when there are no findings, and we are getting them denied by Medicare indicating that it is not edically necessary. I have recently learned that as of 10/01/2024 we have to bill Z86.0100 as a secondary diagnosis. Should I be using Z12.11 or Z09 as the primary diagnosis?
 
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lindaf said:
Needing clrification on patients with a hx of colon polyps. Currently we are billing surveillance colonoscopy with G0105 with Z86.0100, when there are no findings, and we are getting them denied by Medicare indicating that it is not edically necessary. I have recently learned that as of 10/01/2024 we have to bill Z86.0100 as a secondary diagnosis. Should I be using Z12.11 or Z09 as the primary diagnosis?
Click to expand...
You should be using Z09 as primary as this is a surveillance. Z12.11 should be used as primary dx when it’s family hx of colon polyps or first degree family hx of colon cancer.
 
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We are using Z09 as primary and then the new history of polyps code with the G0105 and getting denials from Medicare WPS. anyone else having the same issue?
 
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I am getting some denials from Medicare Advantage Plans on G0105, using Z09 as primary and Z86.0101 as secondary. The denial states due to NCD 210.3. When I look up the NCD, it doesn't list a colonoscopy as one of the tests for Colorectal Screening. Anyone else have this happen? We are in the process of appealing the denials with information found regarding Medicare coverage for screenings. The NCD is very deceiving, Medicare should fix the wording.
 
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TamGIGal said:
I am getting some denials from Medicare Advantage Plans on G0105, using Z09 as primary and Z86.0101 as secondary. The denial states due to NCD 210.3. When I look up the NCD, it doesn't list a colonoscopy as one of the tests for Colorectal Screening. Anyone else have this happen? We are in the process of appealing the denials with information found regarding Medicare coverage for screenings. The NCD is very deceiving, Medicare should fix the wording.
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TamGi
Ahh does the patient have a problem such as K92 Digestive or K64 or K59 or R15 reason for colonoscopy? Or use dx K63.89 Disease of Colon unspecified since checking colon again Then Z68.010 if supported and Z12.11. The dx Z09 is not first listed dx code and Z68.010 as 2nd dx is ok
I hope this data helps you
Lady T
 
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Patient does not have any signs, symptoms or abnormal diseases of colon. The reason for the colonoscopy is follow-up due to hx of adenomatous polyps (and nothing found during colonoscopy). The coding is correct per coding guidelines; the Z09 follow-up code should be listed first then the Z86.0101 hx of code is to be 2nd. I have been coding this way for years without any denials. Something changed since the 10/1/2024 New ICD10 codes. NGS Medicare didn't accept Z12.11 as diagnosis when using G0105, in the past. Maybe I should try using that as the primary and then Z86.0101 as 2nd.
 
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I deleted my 1st post after seeing these responses and I need help. What about the history codes? Do I need to remove them as per management?
I'm being instructed to remove the Z86.0101 if polyps are found during the surveillance/ screening colonoscopy.

Per my management: "Remove Z86.0101. ICD-10 guidelines state not to use a history of a condition code if the condition still exists. As present polyps were found, the condition still exists."
If I remove Z86.0101 how will the payer know that this is a screening within the 10 year period? The previous polyps were removed. These are new polyps, how can I get my management to understand this?
Or am I wrong?
I was also informed: "If a patient came in for screening / hx of polyps. Patient was found to have Polyps so therefore it is no longer a history as they have active polyps."
"If the patient came in for a screening/surveillance. And the colonoscopy turned diagnostic because polyps were found and removed, you would not code the personal history of polyps anymore, per ICD-10 guidelines. ICD-10 guidelines state not to code a history of a condition if the condition still exists. It is our policy to code per these guidelines. You would use Z12.11 and append the -33 or -PT modifier to the CPT code. That will let the carrier know it is a screening/surveillance. I have not come across any instances where the payers are pushing back on these. The payer has the information on how long ago the colonoscopy was. If they don’t, they can request it from the facility. But we are to code per the op report, and the personal history of polyp codes would not be used if a present polyp is found/removed.

I have disputed this 3 times with no avail. I have been coding for over 20 years and have never been told to remove hx codes if they apply. PLEASE HELP.
 
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TThivierge said:
TamGi
Ahh does the patient have a problem such as K92 Digestive or K64 or K59 or R15 reason for colonoscopy? Or use dx K63.89 Disease of Colon unspecified since checking colon again Then Z68.010 if supported and Z12.11. The dx Z09 is not first listed dx code and Z68.010 as 2nd dx is ok
I hope this data helps you
Lady T
Click to expand...
You cannot just put a diagnosis code on the claim to get paid. If K63.89 is not on the Op report, you cannot put it on the claim. If it is on the Op report, then it is not a screening/surveillance claim.
 
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We are in MI and getting the claims processed with G0105 using Z86.0101 as the Primary Dx 6 years after a colonoscopy removing a polyp. It is processing to patient deductible and not as a preventative benefit. I can't find written guidance suggesting to use the Z09 as Primary from the payers so we are reluctant to just add it on. Any written guidance from WPS Medicare or BCBSm that anyone has would be helpful.
 
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