Wiki Medicare coding for colonoscopy

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ngastroent

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Hi everyone! I was reading other posts but wasn't finding a clear answer. I code for the physician side of claims for gastro. A Medicare patient (technically Aetna) was seen for a 5 year surveillance colonoscopy due to his history of tubular adenomas. No polyps were found this time, so I coded G0105 with diagnosis codes of Z09 and Z86.0101. Aetna paid us in full. The facility used Z12.11 and Z86.0101. Aetna denied their claim so they're sending the patient a bill for $2000+. I've spoken to the facility billing department (they won't let me speak to the coder though), as has the patient, but they're stating those codes are correct and it's Aetna who's not processing the claim correctly. Does anyone specifically bill for the facility side who could tell me using Z12.11 is correct in this case? I've spoken to 2 other facilities we go to, one says they wouldn't use Z12.11 and the other says they would use it. Frustrating as it should be covered by insurance so hoping to help the patient not need to pay that bill.
 
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I recommend using Z12.11 – Encounter for screening for malignant neoplasm of the colon, as the previously treated condition has been eradicated and there is no ongoing clinical indication to monitor for its recurrence. Therefore, coding it as personal history does not fully reflect the clinical intent of this encounter.


While Z86.0101 – Personal history of adenomatous and serrated colon polyps indicates a healed condition, it does not support medical necessity for active evaluation. The current necessity is to screen for any potential malignancy at the same site, which aligns more appropriately with a screening code rather than a history code.


This approach ensures accuracy in documentation and billing while reflecting the preventive nature of the visit. Hope i make sense:-)

Thanks,
1751275725730.pngDr. Beula Selvan. B.P.T.,CPC1751275734678.png
 
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I think the problem is with Aetna. I have had several G0105 colonscopies denied recently by them. Even after sending in records for previous exam, pathology. I get denial 119 Benefit maximum for time prior has been reached, and N587 Policy benefits have been exhausted. I sent for reconsideration, still denied. When I actually spoke with someone at Aetna I was told they already paid that procedure code to the facility, so therefore the benefits were exhausted. They were going to have the claim reviewed again.
 
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lindam@caricures.com said:
I think the problem is with Aetna. I have had several G0105 colonscopies denied recently by them. Even after sending in records for previous exam, pathology. I get denial 119 Benefit maximum for time prior has been reached, and N587 Policy benefits have been exhausted. I sent for reconsideration, still denied. When I actually spoke with someone at Aetna I was told they already paid that procedure code to the facility, so therefore the benefits were exhausted. They were going to have the claim reviewed again.
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Good to know, thank you for mentioning that! So frustrating!
 
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lindam@caricures.com said:
I think the problem is with Aetna. I have had several G0105 colonscopies denied recently by them. Even after sending in records for previous exam, pathology. I get denial 119 Benefit maximum for time prior has been reached, and N587 Policy benefits have been exhausted. I sent for reconsideration, still denied. When I actually spoke with someone at Aetna I was told they already paid that procedure code to the facility, so therefore the benefits were exhausted. They were going to have the claim reviewed again.
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FYI the patient just called me, she had filed a grievance to Aetna with my letter, facility's letter and records, Aetna did overturn it and paid their claim in full
 
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Per Medicare, a history of polyps surveillance is considered a screening. Aetna is supposed to follow Medicare guidelines if they are the MAC. The correct coding is Z12.11, Z86.010x unless a polyp was found.

Colonoscopy coding has become very confusing due to the different payers having different policies regarding a history of polyps.
 
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