Gastroenterology Coding Alert

Question: We did a colonoscopy with biopsy ( CPT 45380 ) on a Medicare patient. The primary diagnosis was change in bowel habits (787.99). The secondary code was family history of colon cancer (V16.8). Why were we denied twice?

Connecticut Subscriber

Answer: The diagnoses reported probably are not covered by your Medicare carrier, explains Mary T. Bland, CPC, an independent coding consultant in Mesa, Ariz. If you had been more specific in your use of diagnostic codes, you might not have been denied.

What specifically was the change in the patients bowel pattern? If he or she had functional diarrhea (diarrhea with no detectable organic cause), you could have reported diagnosis code 564.5, which is covered by Connecticuts Medicare carrier. If the patient had blood in stool, you could report 578.1, which is also covered.

What did the pathology lab give as the clinical diagnosis of the specimen that was taken? If there was a pathological finding (benign or malignant), that should have been your primary diagnosis code, Bland says. Possible codes that could have been used (depending on the pathology results) include 211.3 (benign neoplasm of the colon) or 153.6 (malignant neoplasm of the ascending colon), both of which are covered by Connecticuts local medical review policy.

Many local Medicare carriers list V16.0 (family history of malignant neoplasm, gastrointestinal tract) as a covered diagnosis code for a screening colonoscopy (HCPCS code G0105), but Connecticuts local medical policy does not.

Note: The correct diagnosis code to report a family history of colon cancer is V16.0 and not V16.8, which is what you used and is not as specific a diagnosis.

If you are unsure about which diagnosis codes are covered by your carrier, you can request a copy of its local medical review policy for colonoscopies. You may also be able to research the policy on the Internet at the Connecticut Medicare Web site, at www.connecticutmedicare.com.