Colonoscopy: Screening or Surveillance?
- By admin aapc
- In Industry News
- March 1, 2013
- Comments Off on Colonoscopy: Screening or Surveillance?
By Anna Barnes, CPC, CEMC, CGSCS
Consider patient history and reason for the visit for accurate diagnosis coding.
The advent of the Affordable Care Act (ACA) has increased patient access to a greater number of preventative services. Physicians and patients have both benefited from this new law. Patient disease processes are being diagnosed at an earlier stage, ensuring less invasive treatments and better outcomes, while physicians are seeing an increase in revenue for preventative services.
Practices performing colonoscopies for colon and rectal cancer screenings have seen a corresponding rise in requests for “screening” colonoscopy. As a result, there is an increase in incorrectly coded colonoscopies. Practices may not understand that a majority of patients are actually not screening colonoscopies, but are following surveillance regimens. There are several steps you must take to determine the difference and correctly code colonoscopy.
Step 1: Define Screening vs. Surveillance Colonoscopy, Determine Patient Need
Physicians and coders must be able to distinguish between a screening and surveillance colonoscopy. As defined by The U.S. Preventive Services Task Force (USPSTF):
A screening colonoscopy is performed once every 10 years for asymptomatic patients aged 50-75 with no history of colon cancer, polyps, and/or gastrointestinal disease.
A surveillance colonoscopy can be performed at varying ages and intervals based on the patient’s personal history of colon cancer, polyps, and/or gastrointestinal disease. Patients with a history of colon polyp(s) are not recommended for a screening colonoscopy, but for a surveillance colonoscopy. Per the USPSTF, “When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.”
The USPSTF does not recommend a particular surveillance regime for patients who have a personal history of polyps and/or cancer; however, surveillance colonoscopies generally are performed in shortened intervals of two to five years. Medical societies, such as the American Society of Colon and Rectal Surgeons and the American Society of Gastrointestinal Endoscopy, regularly publish recommendations for colonoscopy surveillance.
The type of colonoscopy will fall into one of three categories, depending on why the patient is undergoing the procedure.
Diagnostic/Therapeutic colonoscopy (CPT® 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure))
Patient has a gastrointestinal sign, symptom(s), and/or diagnosis.
Preventive colonoscopy screening (CPT® 45378, G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
Patient is 50 years of age or older
Patient does not have any gastrointestinal sign, symptom(s), and/or relevant diagnosis
Patient does not have any personal history of colon cancer, polyps, and/or gastrointestinal disease
Patient may have a family history of gastrointestinal sign, symptom(s), and/or relevant diagnosis
Exception: Medicare patients with a family history (first degree relative with colorectal and/or adenomatous cancer) may qualify as “high risk.” Colonoscopy for these patients would not be a “surveillance,” but a screening, reported with HCPCS Level II code G0105 Colorectal cancer screening; colonoscopy on individual at high risk.
Surveillance colonoscopy (CPT® 45378, G0105)
Patient does not have any gastrointestinal sign, symptom(s), and/or relevant diagnosis.
Patient has a personal history of colon cancer, polyps, and/or gastrointestinal disease.
Step 2: Properly Report Personal/Family History with Screening/Follow-up
According to ICD-9-CM Official Guidelines for Coding and Reporting, section 18.d.4:
There are two types of history V codes, personal and family. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure.
Common personal history codes used with colonoscopy are V12.72 and V10.0x Personal history of malignant neoplasm of the gastrointestinal tract. The family history codes include V16.0 Family history of malignant neoplasm of the gastrointestinal tract; V18.51 Family history of colonic polyps; and V18.59 Family history of other digestive disorders. Lastly, V76.51 describes screening of the colon.
Per the ICD-9-CM official guidelines, you would be able to report V76.51 (screening) primary to V16.0 (family history of colon polyps). In contrast, you would not use V76.51 (screening) with V12.72 (personal history of colon polyps) because family history codes, not personal history codes, should be paired with screening codes. Personal history would be paired with a follow-up code.
Just because you get paid doesn’t mean the coding is correct: Most carriers will pay V76.51 with V12.72 because their edits are flawed and allow it. The patient’s claim will process under a patient’s preventative benefits with no out-of-pocket; however, an audit of the record with the carrier guidance will reveal that the claim incorrectly paid under preventative services when, in fact, the procedure should have paid as surveillance. The best strategy is to contact your payer to be sure you are coding correctly based on that payer’s “screening vs. surveillance” guidelines.
Step 3: Understand Government and Carrier Screening Definitions
Following USPSTF recommendations, the ACA preventative guidelines state patients with a personal history of adenomatous polyps and/or colon cancer are not covered under a screening guidance, but rather under a surveillance regimen. Many third-party payers also have incorporated the personal history, shortened interval surveillance colonoscopy concept into their policies.
Surveillance colonoscopies are most often covered under diagnostic benefits, even if the patient is asymptomatic. Guidelines are inconsistent across payers; check with your individual payers for their guidelines.
Step 4: Educate the Patient
Under the ACA, payers must offer first-dollar coverage for screening colonoscopy but are not obliged to do so for a surveillance or diagnostic colonoscopy. The patient’s history and findings determine the reason for and type of colonoscopy, driving the benefit determination. This can be very frustrating for patients who may not understand why they are being charged for what they thought was a covered, physician-recommended “screening.” In fact, that screening might be a follow-up (surveillance) colonoscopy, or may become a diagnostic colonoscopy if there are findings.
To avoid angry, confused patients, educate them about the types of colonoscopy (preventative, surveillance, or diagnostic) and insurance benefits associated with each procedure. Accomplish this by providing the patient with the correct tools. Atlanta Colon and Rectal Surgery ask patients to review the “Colonoscopy: What You Need to Know” form (see Form A) prior to coming into the office to schedule their procedure. This form includes defining the patient procedure type, giving the patient the CPT® and ICD-9-CM codes to call insurance, and informing them of the practice policy of not illegally changing documentation to produce better benefit determination.
During the scheduling process, the scheduler will present the “Colonoscopy Notification Form” (see Form B), and discuss the patient’s responsibility for obtaining his or her insurance benefit.
Step 5: Correctly Apply the Principles
Scenario 1: An asymptomatic patient is scheduled for a colonoscopy. The patient had an adenomatous polyp removed from the descending colon two years ago. The patient has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
Rationale: The patient’s last colonoscopy was two years ago. He is being followed by a surveillance regime due to his history of polyps. ICD-9-CM guidelines do not allow the use of the V76.51 screening code with the V12.72 personal history code.
Scenario 2: An asymptomatic patient is scheduled for a colonoscopy. The patient is 50-years-old and has a mother who was diagnosed with colon cancer at age 55. The patient has never undergone a colonoscopy and has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
ICD-9-CM: V76.51, V16.0
Rationale: The patient is 50-years-old and never undergone a colonoscopy procedure. His only relevant history is a mother with colon cancer; family history. ICD-9-CM guidelines allow the use of the V76.51 screening code with the V16.0 family history code.
Scenario 3: An asymptomatic Medicare patient is scheduled for a colonoscopy. The patient had an adenomatous polyp removed from the transverse colon five years ago. The patient has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
HCPCS Level II: G0105
Rationale: This is a Medicare patient with a history of adenomatous polyps undergoing a colonoscopy only five years from the last one. The patient is considered high risk under Medicare guidelines. ICD-9-CM guidelines do not allow the use of the V76.51 screening code with the V12.72 personal history code.
Scenario 4: An asymptomatic Medicare patient is scheduled for a colonoscopy. The patient was recently diagnosed with breast cancer and has never undergone a colonoscopy. The patient has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
HCPCS Level II: G0121
ICD-9-CM: V76.51, 174.9 Malignant neoplasm of breast (female), unspecified
Rationale: This is a Medicare patient with no personal or family history of gastrointestinal disease; breast cancer is not considered an indication under Medicare guidelines. The patient is classified as an average risk screening.
Screening and surveillance colonoscopy coding is driven by the diagnosis and reason for the visit. Physicians and coders must take the time to educate themselves on the definition and guidelines, both coding and carrier, to correctly bill colonoscopies.
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I shared this article with the office. I think this a great educational tool for the front desk; as you know, that is where it all starts. The article provided a very clear determination between a screening and diagnostic colo. The forms in the article would be very helpful for our patients and staff. Is there any way to get a copy of them?
I found this the single most helpful article addressing our issues with coding. Is there a way to obtain a copy of the forms that are listed here? Thank you for sharing such insightful accurate information.
Can you tell me where I can find detailed information regarding this on the Medicare website? I have not had luck in finding info stating that this is per Medicare guidelines. Any help would be appreciated. Great article!
The forms mentioned in the article can be found on the Atlanta Colon website at http://atlantacolon.com/for-patients/. You are welcome to print and use them.
Melissa: Original Medicare processes average risk and high risk colonoscopies under the same benefit determination. See MLN matters SE0613 for coding guidance. High risk colonoscopies (every 2 years) should have a primary high risk diagnosis indicating it is a high risk patient. not V76.51. You should check with each payer including Medicare Advantage/CMOs regarding how they want screening and surveillance (high risk) colonoscopies coded for appropriate beenfit determination.
CMS publishes several guidelines for Colonoscopy:
MLN Matters: http://www.cms.gov/Outreach-and-Education/Medicare…/SE0613.pdf
(Guidelines for Screening colonoscopy average risk versus high risk coding guidance)
USPSTF Guidance: http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colosum.htm
(See not regarding history of polyps under Implementation)
(See page 14, note the heading if you have Original Medicare. Medicare Supplments do not always follow Medicare benefits determinations. )
I hope this helps!
Excellent article. I am a patient who was inaccurately quoted in advance codes V12.72 and 45378 by the doctor’s scheduling representative who research the codes to be used and called back with these codes. I then called the insurer to verify this would be covered as screening. I did have a history seven years ago and polyps were removed. The wrong codes were quoted to me by the doctor’s office. I am more educated now after V12.72 and 45385f were actually used. One appeal process later with the insurance company and personal letter to the doctor both of which only talk of the accurate coding being used (which I now don’t disagree with), I am footing the out of pocket expenses. I am the angry and frustrated patient spoken of in the article still wondering why bad info is being given patients and what recourse is left other than to roll over and pay the bill.
Why were the follow-up codes V67.XX NOT used in the example with hx of polyp/s? I believe I’ve read this in one of the Coding Clinics. Does Medicare and other payers accept personal history codes as primary diagnosis?
Please refer to Coding Clinic 1995, Q1 for use of follow-up codes (V67.XX) for surveillance colonoscopy for hx of GI cancer, with normal findings.
The problem lies with the V12.72 described as “personal history of colon polyps”. Further literature describes it as personal history of “adenomatous” polyps. Confusion comes with coding for hyperplastic polyps. Hyperplastic polyps found are “personal history of colon polyps”, but is a follow up for hyperplastic polyp considered a surveillance, V12.72? Or would it be V76.51 “screening”?
I respectfully disagree with facilities (incorrectly) coding what is by definition, a preventative procedure, regardless of what is found. What is a screening, if not to detect and remove something that could cause cancer? Worse, is facilities coding non-cancer things such as hemorrhoids and diverticulitis, as diagnostic, labeling the patient as ‘high risk’, automatically coding subsequent procedures as diagnostic. For things that have nothing to do with cancer risk!
To call detection/removal of a polyp a treatment, thus diagnostic, is nothing more than a sleight of hand to shift the financial burden away from facilities and insurance providers, onto consumers. If consumers weren’t already hesitant to have a colonoscopy, this new financial burden will seal the deal.
The intent of federal legislation, and some state laws, was to encourage consumers to have this life-saving procedure. That health facilities have taken advantage of distorting what is truly a preventative procedure, thus preventing consumers from having a colonoscopy, is reprehensible.
I, too, am a patient caught in the middle of a medical practice trying to code accurately and my insurance company saying that the provider could change the coding to a screening so my insurance would cover it. I had one polyp removed 3 years ago, and according to my Dr. office, I will now, FOREVER, be considered “high risk” and will have my screenings coded as such. So basically, the Afforadable Care Act only will cover those individuals who never have a polyp! That is unacceptable, considering that according to the American Cancer Society/Kaiser Family Foundation/National Colorectal Cancer Roundtable Report, “polyp removal is a routine part of screening taking place in approximately HALF of screening colonoscopies for patient’s who are at average risk”. Therefore, HALF of all people who have a screening colonoscopy will then be considered “high risk” in the future and NOT be covered for further colonoscopies!?! I am in the process of appeal with my insurance company. Oh, did I mention that my provider NEVER mentioned any of this to me before the procedure? I am not in the medical field, but I am getting an education the hard way.
After reading, it is obvious that Anna is “on the side of insurance carriers” with her opinion. The insurance carriers avoid paying for colon cancer preventive screening health care by “twisting” the diagnosis into the term “surveillance program”. I suspect that Anna is/was “swayed” by the insurance carriers she works with.
While this article was published before the Coding Clinic update, I would encourage the author and readers to check the AHA ICD-9 Coding Clinic for the 4th quarter 2013 under surveillance colonoscopy. There it states that a surveillance colonoscopy should still list V76.51 as the first listed diagnosis, then V12.72 for the personal history of polyps. According to AHA, “A surveillance colonoscopy is still a screening, and patients are being screened for malignancy; however it is considered a high-risk screening exam due to the history of previous polyps.” I believe the author may be using payor guidelines instead of Coding Clinic.
I am still trying to get my medicare advantage plan to pay 100% of the bill from the anesthesiologist for a screening colonoscopy. What is the point of having no co-pay for the gastric surgeon of I must still have a co-pay for anesthesiologist? Do they expect no anesthesia?
This article is out of date and has incorrect information. Colonoscopies were addressed in the Affordable Healthcare Act when it was first released, with clarification released February 2013 in reference to high risk patients.
Also, the patient needs to know if they are covered by a grandfathered or non grandfathered health plan when it applies to the Affordable Healthcare Act as non grandfathered plans cover high risk patients that are asymptomatic under the preventive portion of their policy. Some policies still require the patient to be responsible for any lab charges.
The American Gastroenterology Association states:
The patient with no GI symptoms is referred for a screening colonoscopy for the following reasons:
• Patient age 55 with no high risk factors.
• Patient has personal history of colon cancer or colon polyps.
• Patient has family history (first degree relative) of colon cancer or colon polyps.
And they further state “A patient that has no current symptoms, but a history of polyps or cancer, identified during a previous procedure that has a surveillance colonoscopy is a high-risk screening.”
When the claim denies, or processes to the patients deductible, insurance companies advise the subscriber that the physician did not file the correct codes as they want the practice to file V76.51 in addition to the V12.72 diagnosis, but in my experience the practice I dealt with feels it would be fraud to file both diagnosis codes. This then puts the patient in the middle, with the insurance company nor the physician’s office making a move to get the claim paid. Wish I had the AHA ICD-9 Coding Clinic for the 4th quarter 2013 to show them!!
I am afraid this may lead consumers to not have their colonoscopies due to not having the means to pay out of pocket.
When a patient is referred to a Gastroenterologist because the patient’s age 55 requires a Screening Colonoscopy, but the patient doesn’t have any Personal History, nor Family History and he/she doesn’t have any symptoms at all, the gastroenterologist performs and Evaluation and Management in the office and everything is fine with the patient, the physician documents in the assessment portions of the progress note “Screening Colonoscopy” and the Colonoscopy is schedule in 3 weeks.
What would be the correct diagnosis code for the E/M.
I would report the E/M cpt code with V76.51 for the reason of the visit; but there is some discrepancy on how to code this scenario among the coders where I work. I need clarification for this scenario that we come across everyday.
The information about the coding for the surveillance colonoscopy seems to conflict with the information put out by the American Gastroenterological Association, which says a surveillance colonoscopy should be considered a high-risk screening with no current symptoms and history of polyps:
I have always been confused regarding the following… A patient is getting a colonoscopy and is s/p liposarcoma removal with partial colectomy (not sure how long ago) and positive family history of colon ca. Would I code the colonoscopy as a high risk or would I code it as a diagnostic?
This is crazy! I don’t care what article I read, there is conflicting information regarding coding “surveillance” colonoscopies. For a Medicare patient, when nothing is found, the high risk “screening” G0105 is used and the patient does not have out-of-pocket. For that same patient, if a polyp is snared, for example, and 45385 is used, they have out-of-pocket. Why should they be penalized just because a polyp was found? AGA says to add the PT/33 modifier to the 45385 for a patient with a personal hx of polyps. That seems to go against what this author says (the use of modifiers are not mentioned in this article), AND what the USPSTF says about a patient followed by a surveillance regimen and screening is no longer applicable. Medicare and commercial payers rules are never the same either. So who do you listen to? Sarah is right – patients may decide not to have a procedure due to the expense, and patients with a high risk personal history could be at even more risk as a result, which is scary. What is the correct answer?!
As Rose asked earlier, a history of hyperplastic polyps does not increase surveillance. Why would this matter?
Can someone answer?
CC4Q2013 pg 104: Surveillance colonoscopy. Assign V76.51 and V12.72 “A surveillance colonoscopy is still a screening…”
There haven’t been any recent posts on here but I have to write to thank all of you who wrote comments and explanations on here. In particular those that quoted the guidelines 4th quarter coding clinic that a “surveillance colonoscopy is still a screening…”. I am a patient who had polyps one time nearly 10 years ago and no polyps since then at two other screenings. I had no problem with insurance coverage in previous years but at my most recent colonoscopy, my insurance company would not pay as a preventive service because of my previous polyps – it was now considered diagnostic. The unexpected cost to me would have been over $4,000. But with all the research I did and help from the comments here and elsewhere, I was able to gather enough information to appeal and get that decision reversed so that it was covered in full. My father had colon cancer so I have been diligent about the recommended screenings. I am exactly the population that should be screened and colonoscopies (and polyp removal) are truly preventive. I am worried that many others in my situation would not be inclined to do the research and make an appeal. And worse yet, there will be others that will not go for the procedure for fear of the cost. There will be more cancer, more mortality and ultimately more cost for patients and insurance companies to treat the disease that could have been prevented. Now that there is a healthcare law, shouldn’t all insurance companies be required to pay in the same way for preventive services and determine what is preventive in the same manner? It seems that different insurance companies are following their own rules. That would be understandable if the policy benefits were different but colonoscopies are one of the benefits required by the healthcare law. I think there needs to be some uniformity. What can be done about this? Once again, I am so grateful to all of you who took the time to write in.
This article was very helpful and I have shared this with my co-workers as well. I do have one coding scenario to run by you that TRULY confuses me.
Scenario: Asymptomatic patient comes in for Surveillance Colonoscopy due to personal history of colon polyps removed 5 years ago. During the exam, a polyp is found and removed. How would this be coded?
To me, this is not a screening so I wouldn’t use V76.51 or in ICD-10 Z12.11. I would code is with the personal history as the admit diagnosis (v12.72 or Z86.010) with the current polyp diagnosis as my primary?
This is the only scenario not discussed and I am interested in how it would be coded. Normally, you would not code a personal history code with an existing condition but how else could this be coded?
Stephanie Jones …I would code this as a personal history of Z86.010, K63.5. I would use a 33/Pt modifier on the 45380 if forceps or 45385 if snare.
I have a scenario which is never discussed on any forum.
IBD (Crohn’s/Colitis) patients
They come in for a surveillance colonoscopy every year or every two years
Whether they have active symptoms or are in remission, they get biopsies throughout the colon. So it will always be billed with 45380.
There is no personal history of Crohn’s or Colitis DX code so I usually use personal history of other Z87.19.
I will use a 33 or PT modifier on patients who are in remission.
But my doctors get annoyed because they feel all patients should have it coded so the patient isn’t responsible. They use the term screening and patients get mad when they receive a bill.
Insurance companies like Oxford will process the claim as diagnostic unless the Z12.11 and 33 modifier is listed. I was told for these patients to NEVER use Z12.11 since this is for an average risk screening code and these patients have a history of….
WHAT IS THE PROPER WAY TO CODE THIS?
I would be interest in what M Margaret (or any other) found in the way of “research” the was used with the appeal on reversal of her insurance claim. I am in a similar situation where I thought I was getting a routine screening colonoscopy which would have been covered 100% by my insurance. I now find that the doctor’s office coded the procedure as having a history of polyps and now have an out of pocket expense of $1,000. The letter initially send by my doctor remained me that it was time for my 10 year colonoscopy “screening”. There was no information about diagnostic versus surveillance or potential impacts on my coverage. I was left in the dark.
As a patient who had a polyp removed, I will certainly put off my next colonoscopy. Sure, it’s a risk of not discovering cancer, but cancer care is covered by my insurance.
I am questioning the same scenario as above. Pt has history of colon polyps Z86010. Coming in for surveillance colonoscopy, found 2 polyps removed by snare 45385. I have been using Z09 encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm as the primary diagnosis since Z86010 would be inappropriate. I would also appended the PT/33 modifier to the CPT code since technically this is a screening per CC4th qtr. 2013.
I have a question pt had colonoscopy 10 years ago and had a polyp removed and is coming in for another colon is this done as a screening or as a colon recal
I have a question, a 51 yrs patient with a family history of colon cancer has a colonoscopy and during the procedure they found a polyp and it was removed and sent for biopsy. His previous colonoscopy was 5 years ago. Insurance is BCBS. What are the appropriate codes for this scenario?