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Gastroenterology Coding Alert

Don't Wait for New CPT Codes;Maximize Virtual Colonoscopy Payment Now

Published on Mon Mar 23, 2009

Learn whether to file an ABN with 0066T, 0067T.

CMS is set to decide in February whether it will grant national coverage for virtual colonoscopies to screen for colon cancer. But when your gastroenterologist uses the latest technology for diagnostic work -- under the right circumstances -- you can bill right now for computed tomography colonography.

When All Else Fails

Some Medicare carriers, such as Palmetto GBA, accept category III (temporary) codes 0066T (Computed tomographic [CT] colonography [i.e., virtual colonoscopy]; screening) or 0067T (... diagnostic), as appropriate, for so-called "virtual" colonoscopy, also known as CT colonography (CTC).

Even then, you'll have to document a failed "instrument colonoscopy" to expect reimbursement for virtual colonoscopy claims.

"CT colonography is only indicated in those patients in whom an instrument colonoscopy of the entire colon is incomplete despite adequate patient preparation, this episode or in past episode(s)," says Palmetto's policy, or "a history of adverse event with instrument colonoscopy (i.e., perforation), or a clearly documented condition which is incompatible with colonoscopy such as barium enema demonstrating highly tortuous colon, severe strictures, etc."

"There are some unfortunate patients we come across for whom, due to unique contraindications or other complications, this is their best and only diagnostic tool," says Debbie Rooth, CPC, LVN, who works for Mission Internal Medical Group in Mission Viejo, Calif. It's nice to have that much clarity in a local coverage determination, she says; while Palmetto isn't endorsing wide-spread CTC use, "they're explaining why, in some rare cases, it is a valid examination."

Caution: Coverage for 0066T and 0067T is far from universal, with many Medicare carriers holding out. The bottom line? Check with your carrier for coverage before reporting these codes.

"We have to appeal pretty much every diagnostic one that we perform, even when we have the documentation or the diagnosis code to support it," says Kelli Pekios, patient accounts manager at Gastroenterology Consultants SC in Moline, Ill. "It is a lot of work, but we do manage to get them paid."

What is virtual colonoscopy: CT colonography (virtual colonoscopy) is an enhanced abdominal CT scan in which computerized reconstruction allows physicians to perform a detailed, 3-D examination of the bowel for polyps, cancer, or other disease.

Carefully Document Medical Necessity

Supporting diagnoses: For 0066T, you would use V76.51 (Special screening for malignant neoplasms; colon).

For 0067T, you would provide V64.3 (Procedure not carried out for other reasons) when the physician attempted an instrument colonoscopy but did not complete the service or when the physician determines that he cannot safely attempt an optical colonoscopy. And you'll need to provide a secondary diagnosis as a reason the physician could not carry out the procedure. For instance, your documentation might support 211.3 (Benign neoplasm of colon) as your second diagnosis.

Payers will expect you to have documentation for both the virtual colonoscopy and the failed colonoscopy available upon request.

Components: These Category III codes include both the technical (modifier TC, Technical component) and physician-reading fee (modifier 26, Professional component). Odds are, your practice doesn't own a CT scanner, so you would bill only for the professional component, while the facility bills for the technical component.

In Rooth's case, her large, multi-specialty clinic recently bought a CT scanner. The gastroenterologists will contract with a radiology group to do the interpretations, she says, "while we bill the technical component."

Make Sure Patient Knows He's On the Hook

Modifier GA (Waiver of liability statement on file) should let Medicare know you have an Advance Beneficiary Notice (ABN) on file.

Example: A patient opts for a screening virtual colonoscopy, so your practice makes sure to get an ABN on file. The ABN instructs the patient that you suspect Medicare won't pay for the service and the patient must choose whether he is willing to receive the service knowing he may have to pay.

The ABN should include an estimate of the cost, and you should have the patient sign and date the document. You report 0066T and append GA.

Tip: If you don't get a signed ABN, append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to let Medicare know you're aware the payer is unlikely to cover the service but you don't have an ABN.

Ensure that you don't obtain "blanket" ABN forms from all or most of your patients. You should only obtain ABNs when your practice has ample reason to believe that Medicare will deny the claim.

New form: Make sure you're using the most up-todate ABN form. A new form goes into effect in March. You can find the new ABN form and filing instructions at www.cms.hhs.gov/BNI. Click on the link for "FFS ABN-G and ABN-L," then download the forms and instructions for "Revised ABN CMS-R-131."

Is CTC the Future of Screening?

Medicare does not cover 0066T, the CTC code for screening. However, many think this may soon change. On March 5, 2008, the American Cancer Society, the U.S.Multi Society Task Force on Colorectal Cancer, and the American College of Radiology recommended CTC as an option for colorectal cancer screening.

Background: "Virtual colonoscopy is poised to become the procedure of choice for mass screening for colonic polyps," says Stony Brook University's Arie Kaufman, PhD, in a press release. Kaufman developed CTC technology at Stony Brook University in Stony Brook, N.Y.

"If all patients 50 years of age and older will participate in these screening programs, over 92 percent of colorectal cancer will be prevented and more than 600,000 lives could be saved worldwide every year through this early detection," Kaufman said.

The American Gastroenterological Association still places its highest faith in a scope. "The AGA Institute supports optical colonoscopy as the definitive screening test for colon cancer," according to gastro.org. "We also support CT colonography and other screening tests, if patients and their physicians believe the alternative test is the appropriate one for them."

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