Colonoscopy - Diagnosis Linkage

[coderguy1939]

I code for an ASC facility and I would like some input on the following coding scenario.

Pre-op DX: Screening
Post-op DX: Cecal polyp removed by cold biopsy, diverticulosis, internal hemorrhoids

Doctor did a colonscopy to the cecum and removed a polyp by cold biopsy. I'm coding 45380

My question revolves around proper DX linkage. In ICD-9 under Section IV Diagnostic Coding & Reporting for Outpatient Services under O. Ambulatory Surgery it states that "if the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding since it is the most definitive". However, if the patient has screening benefits, if you use 211.3 as the first-listed DX the patient's insurance carrier will often make the patient responsible for deductibles and/or co-pays. Screening benifits are often paid at 100%. Should the DX codes be coded:
1)V76.51 2)211.3 3)562.10 4) 455.0 and then only link DX codes 2,3& 4 to 45380? I'd appreciate hearing about how others are handling 3rd party payers. Thanks.

[Eena]

See Coding Clinic, First Quarter 2004, page 11 to 12

It states to code the screening code first. The fact that the test is a screening exam remains, regardless of the findings or any procedure that is performed as a result of the findings.

Medicare, however, has a different rule.

[coachlang3]

Actually, stensven, that is Medicares rule. You show the screening dx as the primary dx.

However, Tricare and alot of private insurances (I'm finding this) don't want to see the conversion. They just want to see what was actually done. It gets more confusing every day with the private payors.

[coderguy1939]

In the above scenario, Medicare directs you to use the screening code as the first-listed DX but to link the second DX, 211.3, to the procedure code. Blue Cross has recently instructed us to follow Medicares rules because patients were complaining that they were not getting to use their screening benefits. For non-Medicare patients, I have followed the ICD-9 guidelines as they pertain to ASCs, but patients want to use their screening benefits. Is this just a matter of coding it with the post-operative DX and dealing with the screening benefits issue on a case-by-case basis?

[coachlang3]

coderguy,

Regarding the case by case statement. Yes, that is exactly what I see happening with non-medicare payors (excluding BCBS, finally). The pt does have screening benefits but the payor has issues if they see it as a routine screening or if they see it started as screening but converted to a diagnostic. The payors will not pay the screeninig benefit if it converts and that is their right, but it stinks. How ethical is it for a doctor to leave a potentially cancerous polyp found and tell the patient after the screening, "hey, found a polyp, it might be cancerous but because your insurance won't pay under your screening benefit you're going to get whacked by a big ded and co-ins and we'll schedule a diagnostic colon at another time or you can just leave the polyp and hope your okay".

I'm sorry if I'm not putting it all into words correctly here. Personally I feel if the pt has a screening benefit and they come in for a screening and something is found they should pay at whatever Co-ins% or ded % they would have pd for a screening. If the screening is pd @ 100% pay the proc that was done at 100%.

It's not our fault that the ins co's have the whole auto accept/reject software and they don't want to have a real pair of eyes checking the claims.

As you can all tell, I have a real beef about this. Everyone but the payor gets the shaft here.

[coderguy1939]

I understand your frustrations. It's strange that a simple procedure like this has so many coders trying to figure out how to apply coding guidelines. Thanks for your input.