Gastroenterology Coding Alert

Recent policy statements aren't what they're cracked up to be

CMS officials caused some confusion in January by stating that you should still bill a screening colonoscopy even if the physician finds a polyp. But a recent clarification makes clear that this statement was a mistake.

Clarification: CMS officials have now set the record straight. -The policy is that if you find a polyp and remove it, you change to the diagnostic code,- says William Rogers, MD, a physician who heads the Physician Regulatory Issues Team at CMS. But you can still use the V code diagnosis (secondary to the diagnosis for the polyp) to indicate that the colonoscopy began as a screening colonoscopy.

In other words: There's been no change in policy. If you find a polyp during a screening, the screening auto-matically becomes diagnostic, and you should no longer use a screening V code as the primary diagnosis code, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. You should list the polyp as the primary diagnosis, especially if the physician performs a biopsy ( CPT 45380 ) or snare polypectomy (45385).

Remember: A physician would never perform a biopsy as part of a screening procedure, Pohlig says. The only exception would be if the patient had colitis and the physician was doing a biopsy for surveillance.

Example: For Medicare patients, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for an average-risk patient receiving a screening colonoscopy, or G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for a high-risk patient.

If, however, the physician discovers a polyp during the screening, you should instead report a diagnostic colonoscopy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).

And when the gastroenterologist visualizes and biopsies the polyp, you should change the primary diagnosis from V76.51 (Special screening for malignant neoplasms; colon) to, for instance, 211.3 (Benign neoplasm of other parts of digestive system; colon).

Another consideration: If the gastroenterologist finds a polyp during a screening and the pathology report indicates that the polyp is a tubular adenoma or villous adenoma, the patient is then at high-risk for future colon polyps and cancer, and therefore qualifies for more frequent screenings.

A final note: If the physician finds a less serious problem, like diverticulosis or hemorrhoids, the screening colonoscopy should remain a screening test, with V76.51 as the primary diagnosis.