Screening Colonoscopy

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I have a patient that is coming in for an evaluation to get scheduled for a Colonoscopy. This is a screening but she has a family history of colon cancer. We billed it with the Z12.11 as the primary diagnosis code but her Insurance company is not paying for that. They are telling her that there is another code to use that states Encounter for Colonoscopy screening. I believe it is the same thing. does anyone have any feed back on this situation.

Thank You
 

Pam Brooks

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[SUP]That is the code for screening colonoscopy. (Encounter for screening colonoscopy NOS). What CPT code did you use? Did you add the modifier? [/SUP]
 

Carbon06

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It depends on the insurance company but the Z12.11 is for the screening only of a person with no personal or family history of cancers or polyps. Since they have a family history of colon cancer the primary code should be Z80.0 Family history of malignant neoplasm of digestive organs. Some insurance companies will pay this code as a screening if nothing was found.
 
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I'm billing just a regular E/M code (ex. 99201-99205). I am not adding any modifiers to code. I figured that the only code that was proper would be the Z12.11. If you know a different way I would greatly appreciate it.
 

thomas7331

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This has come up a few times on the discussion forum and I've also seen this denial from payers. The problem is that you're using a screening ICD-10 code with a problem-oriented visit E&M code. 99201-99215 codes are not screening services, they are E&M visits for the evaluation and management of a problem, which requires a chief complaint in order to support the medical necessity of the service. If this is a healthy patient with no symptoms, then a 'sick visit' code is not appropriate.
 
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If the insurance company will not accept the 99401-99406 codes then what are you suppose to do. The patient was being seen because of a Family history of colon cancer. Should that code go first?

Thank You
 
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