SC BCBS Blue Essentials 00811 Denials

CBScott24

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Hello,

We bill for CRNA's for anesthesia in South Carolina . We recently have been getting denials for SC BCBS Blue Essentials when we bill 00811 (When screening colonoscopy procedure turns diagnostic) as the reason "Benefit Plan does not cover this service." Is anyone else experience this issue/ have a remedy? We have reviewed the medical policy on BCBS website for our state, asked provider services, and used the Snat Chat option without getting a direct answer if policy has changed. We don't have access to any of the Blue Essentials policy details.

Thank you!
 

Davieda Skobel

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There has been a lot of debate regarding the ASA codes for Screening colonoscopies and diagnostic colonoscopies ever since Medicare came out with the new codes in 2018. According to information distributed in 2018 and the code description in my CPT Professional AMA code book for 2019, the correct ASA code for screening colonoscopies, regardless of the outcome is 00812. BCBS should be following Medicare guidelines so the 00812 should work. If you use the screening diagnosis code as your primary code and the findings as your second diagnosis you should get paid.
As soon as we have these codes straight in our practices they will probably change them again so stay tuned! LOL!!!

I know some people are still seeing denials with these ASA codes but we have documentation to support it so use it and fight it if you have to.

Just my opinion.
Good Luck,
Davieda Skobel CLPN, CPC
Columbus Ohio
 

LisaAlonso23

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Sherman, TX
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In addition to the correct information in the response above, make sure to add the PT modifier to 00812 for BCBS if a procedure was done during a screening colonoscopy.

Regular screening:
45378/00812
Z12.11, DX for finding(s), Co-morbidity (to justify anesthesia regardless of PS)

Screening that results in a polypectomy via snare:
45385/00811-PT
Z12.11, K63.5, DX for finding(s), Co-morbidity (to justify anesthesia regardless of PS)

Updated 5/22/2019: use 00811-PT for all payers if a screening results in a polypectomy, biopsy or other procedure.

I have also been told a screening colonoscopy had turned diagnostic only because something was found during the procedure and not because a procedure was done.

For example, a patient (P2) with hypertension went in for a screening and unspecified hemorrhoids were found. This does not constitute a screening turning diagnostic, because nothing was done to treat the condition found.

Coding would be:

45378/00812-P2
Z12.11, K64.9

If you provide what diagnoses you listed, that would help to understand why the claim denied each time.
 
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LisaAlonso23

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Sherman, TX
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At ACE, we were originally told to use 00812-PT for commercial insurance & 00811-PT for Medicare when a procedure was done during a colon screening.

We were recently instructed to use 00811-PT for all screenings that resulted in a procedure.

Ex: Screening with diverticulosis found in patient with OSA
45378/00812
Z12.11, K57.90, G47.33

Screening with polypectomy (Cecum polyp) in patient with hypertension
45380/00811-PT
Z12.11, D12.0, I10
 

docdlg

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In addition to the correct information in the response above, make sure to add the PT modifier to 00812 for BCBS if a procedure was done during a screening colonoscopy.

Regular screening:
45378/00812
Z12.11, DX for finding(s), Co-morbidity (to justify anesthesia regardless of PS)

Screening that results in a polypectomy via snare:
45385/00811-PT
Z12.11, K63.5, DX for finding(s), Co-morbidity (to justify anesthesia regardless of PS)

Updated 5/22/2019: use 00811-PT for all payers if a screening results in a polypectomy, biopsy or other procedure.

I have also been told a screening colonoscopy had turned diagnostic only because something was found during the procedure and not because a procedure was done.

For example, a patient (P2) with hypertension went in for a screening and unspecified hemorrhoids were found. This does not constitute a screening turning diagnostic, because nothing was done to treat the condition found.

Coding would be:

45378/00812-P2
Z12.11, K64.9

If you provide what diagnoses you listed, that would help to understand why the claim denied each time.

Hi Lisa,

Did you find the updated information on a particular website? Have you been able to find this on BCBSSC's web?

Thank you,

Donna Gilbert, CPC, CPMA
 

danachock

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Hi, as soon as I saw BCBS with colonoscopy I wanted to provide a little advice from my experience working anesthesia denials. There may be more than to this then just the procedure code and/or diagnosis code(s). They had very stringent guidelines when anesthesia could be administered for a colonoscopy. I'm not familiar with SC BCBS but with a little digging I believe I located their provider website at:
https://web.southcarolinablues.com/providers/educationcenter/medicalpoliciesandclinicalguidelines.aspx

Once you are on this page select the hyperlink for medical policies (as I displayed in blue below):
Medical Policies
Read the medical policies we use to make clinical determinations for a member's coverage.

This opens a new page: http://www.cam-policies.com/internet/cmpd/cmp/mdclplcy.nsf/DispAlphaList?openform
I then entered "colonoscopy" in the medical policy search box (upper right corner) and found a link for Anesthesia Services.

Opening this page: http://www.cam-policies.com/internet/cmpd/cmp/mdclplcy.nsf/DispContent/DD6152BF7346756F8525811E006321CA?OpenDocument
I think it would be beneficial to see their guidelines. Scroll about 1/4 of the page down and under heading Special Procedures - four sentences below this heading it states the following:

"Most routine gastrointestinal endocopic procedures DO NOT require general anesthesia. Therefore, general anesthesia services are considered not medically necessary. Anesthesia services may be considered MEDICALLY NECESSARY during gastrointestinal endoscopy, colonoscopy and sigmoidoscopy procedures in any of the following situations:
  • Prolonged or therapeutic endoscopic procedure requiring deep sedation
  • A patient has a history of or anticipated intolerance to standard sedatives (e.g., patient on chronic narcotics or benzodiazepines, or has a neuropsychiatric disorder)
  • A patient who is at increased risk for complication due to severe co-morbidity
  • A patient over the age of 70
  • Pediatric patients (age 15 and under)
  • Patients who are pregnant
  • A patient who has a history of drug or alcohol abuse
  • Uncooperative or acutely agitated patients (e.g., dementia, organic brain disease, senile dementia)
  • A patient who has increased risk for airway obstruction due to anatomic variant including any of the following:
    • History of previous problems with anesthesia or sedation
    • History of stridor or sleep apnea
    • Dysmorphic facial features, such as Pierre-Robin syndrome or trisomy-21
    • Presence of oral abnormalities including, but not limited to, a small oral opening (less than 3cm in an adult), high arched palate, macroglossia, tonsillar hypertrophy or a non-visable uvula neck extension, decreased hyoid-ment distance (less than 3cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation or advanced rheumatoid arthritis
    • Jaw abnormalities including, but not limited to, micrognathia, retrognathia, trismus or significan malocculusion.
If the Member does not meet the above criteria, there is no anesthesia reimbursement allowed for endoscopic, colonoscopy or sigmoidoscopy procedures."

As I stated when BCBS MN came out with their policy, I was literally faced with hundreds of denials. It took lots of research and time to complete appeals. Unfortunately on those claims I was unable to identify medical necessity; we adjusted the charges off but I felt we were aggressive with our appeals (secondary appeals when necessary) and our hard work paid off to receive reimbursement.

Almost every anesthesia denial utilized the same adjustment codes on the EOB. 1st one listed was N356 (this service is not covered when performed with or subseq...) along with 96 (non covered charge).

It may be worth a direct phone call to SC BCBS to find out exactly why the claim is being denied and receive insight. I wish you lots of luck for resolution on your denials.

Thanks for listening,
Dana Chock, RHIT, CPC, CANPC, CHONC, CPMA, CPB
Coding Analyst (May 2018-present), Anesthesia, Pathology, & Laboratory Coder (Fall 2012 - May 2018), Denial Specialist (December 2012-December 2016)
 
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