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45380 - Medicare Denial CO-50 (Need help to recode)

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mimranbilling:
Hi everyone,

I work for a provider in Florida and didn't realize that 45380 is not covered under Medicare LCD before to bill it for a patient who was seen at out patient center for Colonoscopy, flexible; with biopsy, single or multiple. Is there any other code which I can bill to Medicare and get it paid?


Billing Codes = 45380 with K57.30 and secondary dx code is Z86.010


Denial Info:

HC:45380, DOS 01/13/2021, Code - M25 - Translation = The information furnished does not substantiate the need for this level of service. If you
believe the service should have been fully covered as billed, or if you did not know and
could not reasonably have been expected to know that we would not pay for this level of
service, or if you notified the patient in writing in advance that we would not pay for this level
of service and he/she agreed in writing to pay, ask us to review your claim within 120 days
of the date of this notice. If you do not request an appeal, we will, upon application from the
patient, reimburse him/her for the amount you have collected from him/her in excess of any
deductible and coinsurance amounts. We will recover the reimbursement from you as an
overpayment

HC:45380, DOS 01/13/2021, Code - N115 - Translation = This decision was based on a Local Coverage Determination (LCD). An LCD provides a
guide to assist in determining whether a particular item or service is covered. A copy of this
policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact
the contractor to request a copy of the LCD.

PROCEDURE NOTES =

PREOPERATIVE DIAGNOSIS:
Colon polyps.
POSTOPERATIVE DIAGNOSES:
1. Colon polyp Transverse colon.
2. Diverticulosis of the colon.
PROCEDURE:
Final
Colonosoopy with polypectomy via hot biopsy and snare.
SPECIMENS:
Polyp,
ANESTHESIA:
Monitored anesthesia control.
ESTIMATED BLOOD LOSS:
None,
COMPLICATIONS:
None.
FINDINGS:
1. One centimeter sessile, polyp in the transverse colon.
2. Diverticulosis sigmoid colon,
Procedure notes - Patient was taken to the endoscopy suite, placed in left lateral Sims position. IV
propofol per Anesthesia. Digital exam was performed revealing normal findings. The
Olympus PCF190 colonoscope was inserted into the anal orifice and passed through the
anal canal, rectum, sigmoid colon, which revealed moderate diverticulosis. The
scope was then further advanced into the descending colon and transverse colon where
approximately t cm sessile polyp was noted in the mid transverse colon area. Using
both hot biopsy forceps and snarn, the multiple biopsies were obtained and then
using the snare at a setting of 30 coagulation setting. the polyp was then
transected down to the mucosa! surface. Good hemostasis was obtained. Further
advancement on into the ascending colon and cecal pouch area revealing normal
findings, Careful withdrawal revealing no other mucosa! abnormalities throughout
withdrawal. Patient tolerated the procedure well and was taken to recovery roomin
stable condition.

Michele:
On the denial it should list the LCD number.  It would be an L followed by 5 numbers.  That would be very helpful in determining the cause of the denial. The only LCD I am finding is L34213 but that doesn't include the 45380.

mimranbilling:
Thank you for looking into this. I dont see any LCD number listed on EOB received by Medicare. I only see below info on the EOB but when I searched the CPT code on Medicare website I found this LCD # L33671

Procedure = HC:45380
DOS = 01/13/2021
Adj.Level = Service
Code = CO_50
Claim Status Group and Reason Code Translation = Contractual Obligation - These are non-covered services because this is not
deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment Information REF), if
present. This change effective September 1, 2017: These are non-covered
services because this is not deemed a 'medical necessity' by the payer. Usage:
Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment Information REF), if present.

Michele:
That LCD doesn't contain the 45380 cpt code.  It actually doesn't specify which cpt codes they accept, which is unusual.  I would try calling Medicare and asking them to pull up that LCD and help you see what CPT codes are accepted.  I see G codes for colonoscopies but those are for screening.  This one appears to not be a screening colonoscopy.

mainiaDup:
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