Preop ECG required for colonoscopy but Medicare denied

I’m new to Medicare and could use some help with this. My doc coded the ECG as “routine” (don’t know the code). The surgery center requires a current ECG before performing the colonoscopy. Medicare denied the ECG. How could my doc code the ECG to make it clear that it was necessary before the colonoscopy? Thanks for any guidance.

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If your doctor codes the ECG for the colonoscopy as “medically necessary” instead of “routine,” it could make a difference. They might also include a diagnostic code that explains the need for preoperative clearance. Discussing this with them will help clarify the reasoning.

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What does routine even mean in this context. Ask them to review the diagnosis code.

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Yes.
The code should reflect that it is a medical necessity since it’s a pre-op exam, which is not covered under routine benefits.

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Sorry, I hate when people refer to things as routine when they shouldn’t. So, what does “routine” mean in this context? Are we just talking about Z codes? I’ve seen too many insurance companies label medical codes as routine codes instead of just using Z codes.

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Not all Z codes are routine.

“Routine” means preventative and qualifies for 100% coverage.

For your doctor, “routine” means they need to check that your heart is stable enough for the procedure, but it should be based on a medical diagnosis (for example, if you have a comorbidity that increases the risk of heart issues).

There might be an ECG covered as routine, depending on age and the plan. you mentioned that this is preoperative.

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Yes, I’ve seen insurance label all sorts of crazy medical diagnoses as routine, like a cancer diagnosis. It’s important to question what insurance means when they say something is coded as routine!

Would any sane person call cancer routine? Absolutely not, but that’s what insurance told a patient! It took forever to get them to call the insurance back for a real explanation.

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Routine cancer screenings do exist, but it depends on your plan. Check your plan’s provisions.

Insurance can’t tell the provider how to bill.

Doctors focus on medicine, not billing.

So, your doctor may routinely screen you for A1C, vitamin D, and other tests that aren’t usually considered routine. However, they see them as routine because if those levels are off, it indicates a problem in the body.

Some plans cover these tests, while others may fight against it.

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No, honey, active cancer and chemotherapy treatment shouldn’t be considered routine. They told the patient that their chemotherapy was coded as routine.

I have no faith in insurance reps after dealing with situations like that. It turns out they messed up some internal coding on their end, but the customer service for the patient couldn’t see anything and didn’t question it at all.

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That happens more often than you think.

Insurance companies often try to avoid paying.

I work in the field and still have to ask, “What are you billing?” It’s important to code and point correctly, and then keep pushing until the issues are fixed.

Right now, my kid’s meds need prior authorization, which we do every year. This year, though, the new person just sent one paper saying there’s a history of use. They didn’t include the extensive testing documentation explaining why this medication is the only one that works.

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Thanks, everyone. Very helpful. I will call my doc and ask them to check the code.

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Majority of the time, they are not covered by Medicare, the surgery center knows this and eats the cost. Unless you sign a wavier, you can not be billed for it unless you go to an outside facility.