Wiki screening colonoscopy turned diagnostic

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LaceyCanon

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My question is this, so for screening turned diagnostic, you bill the code that was done(removal polyp) and use Z12.11 as primary dx with modifier PT or 33 depending on what insurance it is. So if they have more than one polyp removed by different means, example: 45385 & 45384 & 45380, do you put the mod-pt or 33 on all of them and use primary z12.11 on all of them??
 
It depends on the insurance but the modifier needs to go on all of the procedures. check your ncci edits to make sure you can bill 45380 with 45384 since they are both biopsies.
 
What about the dx, should the z12.11 be the first listed on all. And yes they are all separate polyps. I am referring to Medicare and BCBS for the most part. I know others may have their own policy. Do you have any documentation to show that the mod should be put on all codes?
 
Screening turned Diagnostic/Anesthsia

We bill for anesthesia and we are getting denials from Medicare as medical necessity. We are 99% sure it's because of the DX code placement. Should the screening be codes listed as 1. Z12.11 and the finding 2nd. DX code K57.30? and the MOD would be 33 or PT? :(
Thank you
 
Stephvill

Yes the screening 'Z' code should be the primary code on all of the biopsy procedures followed by the DX for the (polyp) findings-- along with the PT modifier. In addition, the anesthesia code for screening colonoscopy turned diagnostic is 00810/PT. The anesthesia code for screening colonoscopy HCPC codes G0105 and G0121 is 00810/33 per CMS - Medicare regulations, Sect 410.37(a)(1)(iii).
 
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Medicare LCD update for our CMS MAC here in FL

There was a 2018 update from our MAC - First Coast Service Options advising of an LCD revision effective 05/17/2018 where Z12.11 (among other such as Z80.0, Z86.010, etc.) are "not appropriate with a diagnostic colonoscopy CPT code" such as 45380, 45384, 45385, etc.

Meaning, although we are going in for Z12.11, I can no longer code Z12.11 as primary when my screening (45378 or G0121) turned diagnostic (45380, 45384, 45385, 45390, etc.)

*** It's always best to check with your MAC or LCD often to see if any updates or revisions have been made. This could help answer recent denial trends you may be noticing with Medicare claims. ***

Hope this helped!!
 
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