Anesthesia: Collect Every Dollar

Correct coding relies on ICD-9-CM diagnosis assignment and sequencing.

By Melissa Fincham, CPC, CPC-H

Diagnosis code sequencing can become a nightmare when wading through all the available coding and regulatory guidance. You can simplify the process by differentiating reimbursement policies set forth by your fiscal intermediary (FI) or Medicare administrative contractor (MAC) from the guidance provided by coding authorities — namely American Hospital Association’s (AHA) Coding Clinic.

Anesthesia and Pain Management CANPC

FIs and MACs have developed countless policies providing specific instructions to allow (or disallow) coverage for tests and procedures. These policies often include requirements for specific CPT® codes, frequency limitations, documentation, and accepted diagnosis codes/code sequence. The AHA has published coding policies serving as the general “rule of thumb” when coding services, regardless of the medical insurance coverage the patient has. The collision of these two worlds is not pretty, and often leaves coders confused as to which advice to follow. For example, let’s consider the Medicare hospital outpatient perspective for screening and diagnostic colonoscopy encounters.

Important! This information is specific to hospital outpatient reimbursement, for Medicare claims submitted on the UB-04 claim form. National Medicare guidelines for physician billing differ from those discussed here. For physician billing rules regarding screening vs. diagnostic colonoscopy ICD-9-CM code sequencing, see Medicare Learning Network Matters SE0746, “Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscopy,” which may be found on the Centers for Medicare & Medicaid Centers (CMS) Web site: Private payers may stipulate different guidelines.

Look to AHA Guidance for Code Assignment

First, let’s review AHA guidance:

AHA Coding Clinic, 4th quarter 2001 advises assigning code V76.51 Special screening for malignant neoplasms; colon as the first-listed code when a patient without a personal history of gastrointestinal disease and without signs and symptoms has a screening colonoscopy, even when the colonoscopy reveals a polyp or other abnormality.
AHA Coding Clinic, 1st quarter 2004 advises assigning code V76.51 as the first-listed code when a patient presents for a screening colonoscopy. Even if the screening exam is converted to a “surgical” colonoscopy (i.e. polyp removal), the fact remains that the patient initially presented for a screening.

LCDs Show Guidance Inconsistency
Review of Local Coverage Determinations (LCD), however, often reveals different guidance. The confines of this publication don’t allow us to go through the LCD requirements from all FIs and MACs, but we can address specific guidance provided by National Government Services (NGS), a Medicare contractor, to get a general idea.
NGS has two LCDs which pertain to colonoscopy:

• Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy (L26404), revised Oct. 1, addresses requirements for colonoscopy other than those done for colorectal cancer screening.
• Colorectal Cancer Screening (L26402) deals specifically with screening exam — that is, no signs, no symptoms, and no chief complaint. In addition to reading the LCD, it’s important to read the supplemental instructions articles (SIA) associated with the LCD, which often contain valuable coding guidance. This is true for any LCD policy you review.
Per NGS’ policy, V76.51 should be the first-listed or principal diagnosis for screening colonoscopy, followed by incidental findings, such as hemorrhoids and diverticulosis. If, however, during the screening exam a polyp is discovered and removed, the exam is no longer considered a screening. Here’s where coding directives under the Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy LCD come into play. Diagnosis code V76.51 is not listed in this LCD as a “covered diagnosis.” This means NGS will not accept V76.51 for colonoscopies that are diagnostic or surgical in nature.

To apply these guidelines, let’s look at a few real-world examples from a hospital outpatient services perspective:

Example 1:
The patient comes in for screening colonoscopy (no indication for high-risk screening). During the exam, a polyp is discovered in the transverse colon and is removed via snare polypectomy. No other abnormalities are noted and the patient is instructed to follow up in two years, pending pathology results. Pathology reveals adenomatous polyp, transverse colon.

ICD-9-CM Diagnosis Code Assignment Using AHA Coding Clinic Guidance
Principal Dx: V76.51
Secondary Dx: 211.3 Benign neoplasm of other parts of digestive system; colon

Remember, according to AHA Coding Clinic, screening diagnosis V76.51 should be the first listed diagnosis code with the finding of “polyp” listed as a secondary diagnosis.

ICD-9-CM Diagnosis Code Assignment Using NGS LCD Guidance
Principal Dx: 211.3

Example 2:
A patient presents with generalized abdominal pain off and on for three weeks. The physician performs a colonoscopy to evaluate and, if necessary, treat the patient. The colonoscopy reveals no abnormality; the cause of the abdominal pain is unknown. Patient is instructed to follow up in the office.

ICD-9-CM Diagnosis Code Assignment Using AHA Coding Clinic Guidance
Principal Dx: 789.07 Other symptoms involving abdomen and pelvis; abdominal pain, generalized
ICD-9-CM Diagnosis Code Assignment Using NGS LCD Guidance
Principal Dx: 789.07

This example is considered a screening exam although no abnormality was discovered. The patient still presented with the complaint/symptom of “generalized abdominal pain.”

This next example is a little trickier, and shows you the application of the recent update to NGS’ Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy LCD.

Example 3:
A patient underwent treatment for colon cancer two years ago. Her most recent colonoscopy was last year. It is time for her repeat colonoscopy for cancer surveillance and follow-up. Colonoscopy was performed to the cecum without difficulty. Slow withdrawal revealed no abnormalities.
ICD-9-CM Diagnosis Code Assignment Using AHA Coding Clinic Guidance
Principal Dx: V67.09 Follow-up examination following other surgery
Secondary Dx: V10.05 Personal history of malignant neoplasm; large intestine
ICD-9-CM Diagnosis Code Assignment Using NGS LCD Guidance
Principal Dx: V67.09
Secondary Dx: V10.05

According to NGS’ LCD revision, effective Oct. 1, V67.09 should be used as the principal diagnosis when the patient has a history of colorectal cancer or polyps and is being followed for that reason. Prior to Oct. 1, this was the case only for the first year after the patient’s initial treatment; the revision, however, removed the phrase “the first year.”

The policy also requires that one of the following ICD-9-CM codes be listed as a secondary diagnosis: V10.05, V10.06 Personal history of malignant neoplasm; Rectum, rectosigmoid junction, and anus, or V12.72 Personal history of diseases of digestive system; Colonic polyps. Take note of the phrase “… and is being followed for that reason.” This indicates that this guidance would not apply if the patient is presenting for some other reason.

This guidance for V67.09 use is in line with advice in AHA Coding Clinic issues published first quarter 1995 and third quarter 2002.
Let’s examine in the following example how the diagnosis assignment changes when the intent behind the exam is altered.

Example 4:
A patient underwent treatment for colon cancer three years ago. Since then, she has done well and has had no problems. She presents today for her regular screening colonoscopy. Her last exam was two years ago. A scope was performed in the cecum without difficulty. No abnormalities were found; and the patient was instructed to repeat the colonoscopy in two years.

ICD-9-CM Diagnosis Code Assignment Using AHA Coding Clinic Guidance
Principal Dx: V76.51
Secondary Dx: V10.05
ICD-9-CM Diagnosis Code Assignment Using NGS LCD Guidance
Principal Dx: V76.51
Secondary Dx: V10.05
In this case, V76.51 is appropriate under NGS guidelines because the patient is being seen for purposes of a screening exam and not specifically for follow-up evaluation of the cancer.

AHA Coding Clinic is the official source for ICD-9-CM guidance, and should be followed unless otherwise specified by your FI/MAC or CMS.

Remember: When coding Medicare services, guidance published by CMS and its related entities (i.e. FI/MAC) takes precedence and is the key to accurate code reporting and sequencing. It is necessary to follow their guidelines to ensure proper claims submission and reimbursement for the services provided.


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