SC BCBS Blue Essentials 00811 Denials

CBScott24

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Local Chapter Officer
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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

Networker
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Columbus Ohio
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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

Expert
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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.
 
Last edited:
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LisaAlonso23

Expert
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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
 
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