Gastroenterology Coding Alert

 What to do with no end to the debate in sight

Reporting screening colonoscopies that become diagnostic hasn't been easy. In fact, the debate has intensified further over the past several months. Looking for written instructions from your carrier may be your only answer.
 
Background: In February, CMS officials clarified that when a screening colonoscopy finds a polyp, you should bill using the polyp diagnosis, not the screening V code.
 
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.
 
But if the physician discovers and removes a polyp by biopsy during the screening, you should instead report colonoscopy with a standard CPT code ( CPT 45380 , 45384 or 45385, depending on method of removal).
 
And when the surgeon 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), as outlined in the instructions CMS provided in February.
 
The retraction: Now, CMS officials are distancing themselves from their earlier instruction, pointing to language in the ICD-9 diagnosis coding guidelines stating that you should still use the screening diagnosis even if you find a problem during a screening exam.
 
-Should a condition be discovered during the screening, then the code for the condition may be assigned as an additional diagnosis,- according to ICD-9 instructions.
 
-I didn't mean to say anything that was contrary to the guidance that CMS has given on this subject,- says William Rogers, MD, head of CMS- Physician Regulatory Issues Team.

Ask for Clarification

Most carriers have come out in favor of switching to the polyp diagnosis for the excision. But a few, including TrailBlazer Health Enterprises, agree with keeping the V code even if you find a polyp during a screening.
 
In addition: The January 2004 CPT Assistant (published by the AMA) also agrees with putting the polyp diagnosis first when the physician finds a polyp and performs a therapeutic procedure, says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC, medical coding instructor for Orion Medical Services in Eugene, Ore.

Watch out: If you list the screening V code first, a serious problem can occur because many Medicare carriers may not pay for the polypectomy. Most carriers don't have the screening listed as a covered diagnosis for diagnostic colonoscopy in their local coverage determinations.
 
Possible solution: Some experts have recommended listing the V code as the primary diagnosis in Box 21 of the claim form, but then including a -2- next to the procedure code in Box 24. This lets the carriers know that the secondary diagnosis, the polyp code, is the one that they should associate with the procedure code. But this might not work with some billing software.
 
Bottom line: For now, you should follow your carriers- guidelines -- whatever they may be -- Felthauser says. If a carrier tells you to list the polyp diagnosis first, do that. But with so many conflicting opinions circulating, you-ll want to be sure to get the carrier's instruction in writing -- that way, you-re covered no matter what happens in the future.