Wiki Screening Colonoscopy resulting in 45390 - EMR


Gypsum, CO
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I'm finding multiple insurance Medical Policies excluding 45390 from the covered Screening Colonoscopy codes. Currently this code is being applied to the patient's deductible (when a covered benefit) even when a 33 modifier and Z12.11 is attached. Is anyone else having this problem. Our biggest commercial insurances are UHC and Anthem BC/BS, both their policies have excluded this. Patient's are getting frustrated. I'm at stand still here, the service was performed but the service is covered under screening. Of course, if you unbundle the code (45385/45381), these insurances will pay under screening. Really look for advice. Thank you.
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Stefanie, I found the the info below, not sure it applies but thought I would send. I also included a list of the DX codes they are say support medical necessity for this CPT, and it does not list Z12.11. The LCD lists this CPT as a Surgery: Colonoscopy (Diagnostic) so if we try to apply the screening dx it will not pay.

Surgical endoscopy includes diagnostic endoscopy; however, diagnostic endoscopy can be identified separately when performed at the same surgical session as an open procedure. Bleeding that occurs as the result of an endoscopic procedure, and controlled during the same operative session, is not reported separately. Do not report 45390 in conjunction with 45378 or with 45380, 45381, 45385, or 45398 for the same lesion.

Multiple Procedure Reduction Guidelines and Endoscopy Base Code - 45390

Special rules for multiple endoscopy procedures apply if procedure is billed with another endoscopy in the same family (i.e.,another endoscopy that has the same base procedure). The base procedure of each code with this indicator is identified in the Endobase field of this file. Apply the multiple endoscopy rules to a family before ranking the family with the other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy. The base endoscopy code for 45390 is 45378 .

A04.5 Campylobacter enteritis
A04.7 Enterocolitis due to Clostridium difficile
A06.9 Amebiasis, unspecified
A09 Infectious gastroenteritis and colitis, unspecified
A18.31 - A18.39 - Opens in a new window Tuberculous peritonitis - Retroperitoneal tuberculosis
A18.83 Tuberculosis of digestive tract organs, not elsewhere classified
C18.0 - C21.8 - Opens in a new window Malignant neoplasm of cecum - Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C77.2 Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C80.0 Disseminated malignant neoplasm, unspecified
C80.2 Malignant neoplasm associated with transplanted organ
D01.0 - D01.3 - Carcinoma in situ of colon - Carcinoma in situ of anus and anal canal
D12.0 - D12.9 - Benign neoplasm of cecum - Benign neoplasm of anus and anal canal
D37.1 - D37.5 - Neoplasm of uncertain behavior of stomach - Neoplasm of uncertain behavior of rectum
D37.8 - D37.9 - Neoplasm of uncertain behavior of other specified digestive organs - Neoplasm of uncertain behavior of digestive organ, unspecified
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
D50.9 Iron deficiency anemia, unspecified
I33.0 Acute and subacute infective endocarditis
I78.0 Hereditary hemorrhagic telangiectasia
K50.00 - K56.2 -Crohn's disease of small intestine without complications - Volvulus
K56.5 - K56.7 - Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection) - Ileus, unspecified
K57.20 - K57.53 - Diverticulitis of large intestine with perforation and abscess without bleeding - Diverticulitis of both small and large intestine without perforation or abscess with bleeding
K58.0 - K59.2 - Irritable bowel syndrome with diarrhea - Neurogenic bowel, not elsewhere classified
K59.8 Other specified functional intestinal disorders
K62.0 - K62.7 - Anal polyp - Radiation proctitis
K62.82 - K62.9 - Dysplasia of anus - Disease of anus and rectum, unspecified
K63.1 - K63.89 - Perforation of intestine (nontraumatic) - Other specified diseases of intestine
K91.850 - K91.858 - Pouchitis - Other complications of intestinal pouch
K91.89 Other postprocedural complications and disorders of digestive system
K92.1 - K92.2 - Melena - Gastrointestinal hemorrhage, unspecified
K92.89 Other specified diseases of the digestive system
Q85.8 - Q85.9 - Other phakomatoses, not elsewhere classified - Phakomatosis, unspecified
R10.0 - R10.33 - Acute abdomen - Periumbilical pain
R10.83 - R10.9 - Colic - Unspecified abdominal pain
R11.13 Vomiting of fecal matter
R19.4 - R19.5 - Change in bowel habit - Other fecal abnormalities
R19.7 - R19.8 - Diarrhea, unspecified - Other specified symptoms and signs involving the digestive system and abdomen
R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract
T18.4XXA Foreign body in colon, initial encounter
Z85.00 - Z85.01 - Personal history of malignant neoplasm of unspecified digestive organ - Personal history of malignant neoplasm of esophagus
Z85.028 Personal history of other malignant neoplasm of stomach
Z85.038 Personal history of other malignant neoplasm of large intestine
Z85.048 - Z85.05 - Opens in a new window Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus - Personal history of malignant neoplasm of liver
Z86.010 Personal history of colonic polyps
Z87.19 Personal history of other diseases of the digestive system