Wiki Claim denial based on LRC or SI

We billed a colonoscopy claim with ICD 10 K52.9, D12.8, D12.2, and D12.5. The CPT is 45385 and 45380 with modifier 59. We have billed these CPT codes with the modifier several times before and they got paid. Community Health denied this claim. The denial description is Services is not payable based on the LRC; line return code or SI; status indicator generated.

What does this denial mean? I’m unsure what CHC wants me to change.

Pat
First dx code should be with D12 blocks, then K52.9 colitis , then last dx code Z12.11 or Z13.811, use XS modifier not modifier 59 since it defines differ areas of colon found polyps. The 2 CPT seem in conflict since both biopsy removal. Did you link each dx with proper CPT treatment? Anytime polyp removed put that first on claim, then other dx and Z dx code last. Colitis does not match up to 45380 or 45385 polyp in colon removed.
I hope this data helps you.
Lady T

TThivierge said:

Pat
First dx code should be with D12 blocks, then K52.9 colitis , then last dx code Z12.11 or Z13.811, use XS modifier not modifier 59 since it defines differ areas of colon found polyps. The 2 CPT seem in conflict since both biopsy removal. Did you link each dx with proper CPT treatment? Anytime polyp removed put that first on claim, then other dx and Z dx code last. Colitis does not match up to 45380 or 45385 polyp in colon removed.
I hope this data helps you.
Lady T

Click to expand...

Thank you for your response. The patient had a colonoscopy due to chronic diarrhea. It was not a screening. Can you please explain why the D12 blocks should be primary and why we should add Z12.11 or Z13.811? We have never had an issue with using both CPT codes. I have never heard of using Z12.11 last since that is usually the reason for the colonoscopy.

patdow said:

Thank you for your response. The patient had a colonoscopy due to chronic diarrhea. It was not a screening. Can you please explain why the D12 blocks should be primary and why we should add Z12.11 or Z13.811? We have never had an issue with using both CPT codes. I have never heard of using Z12.11 last since that is usually the reason for the colonoscopy.

Click to expand...

If polyps are discovered in the colon which be on lab results and provider should explain this in documentation where pluck bx ...you code them as primary. Then I d use dx Z12.11 cause this is why investigating the colon looking for cancer. If not a polyps use a symptom or definitive dx from documentation
I hope this makes sense
Lady T

TThivierge said:

If polyps are discovered in the colon which be on lab results and provider should explain this in documentation where pluck bx ...you code them as primary. Then I d use dx Z12.11 cause this is why investigating the colon looking for cancer. If not a polyps use a symptom or definitive dx from documentation
I hope this makes sense
Lady T

Click to expand...

Thank you. I was taught to always use Z12.11 as primary since that is the reason for the colonoscopy. Is this not accurate if findings are discovered during the colonoscopy?

Patdow
If pt has gastro problem hopefully provider list this as reason...code this dx and dx Z12.11 last. If the results from colon biopsy taken use D12 blocks from wherever the bx are taken from as first dx code on claim. The colon/intestine has like 5 sections in it....you can use K63.5 but it does not give details...payers like details. Also there are different kinds of hemorrhoid see dx block K64 Then add Z12.11 last. If you read the ICD10 manual dx Z12.11 is not first listed z dx code. There are certain Z dx codes which are first and some which are last. Payers will pay on dx Z12.11 is first but if problem discovered you code that first such as cancer in colon, polyps, gastritis, irritation,Etc.
I hope helped you understand better
Lady T