Wiki Medicare denial for Z12.11 and 45380

We billed an invoice to Medicare with ICD 10 codes Z12.11 and K64.1 and D12.7. CPT code is 45380. This means that the colonoscopy was a screening and a colon polyp and hemorrhoids were found. 45380 was used because there was a biopsy performed.

We received a denial stating These are non-covered services because this is not deemed a ‘medical necessity’ by the payor.

Do we need to remove the D12.7 and K64.1 codes?

Patdow
Sequence seems wrong,, first dx D12.7, K64.1 then dx Z12.11 or Z13.811 last. Id use Z13.811 last cause if pt had annual screen already due to age might be reason denying it. However I think it is the sequencing part. Also if pt has had polyps years ago add the Z86.010 last.
I hope this data helps you
Lady T

What about Medicare Category II codes and modifier KX?

• G0105: Colorectal cancer screening; colonoscopy on individual at high risk
• G0121: Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk