General Surgery Coding Alert

Youll now have to turn to ABNs to see payment on these procedures.

If you were crossing your fingers, hoping that CMS would not change its policy on paying for virtual colonoscopies, youll be disappointed. On May 13, CMS issued a decision memorandum indicating that it will not cover screening computed tomography colonographies, which are better known as virtual colonoscopies (VCs). Find out if youll be able to capture payment when your general surgeon uses the latest technology to perform colonoscopies.

Dont Expect Medicare Payment on 0066T, 0067T

Old way: Some Medicare carriers, such as Palmetto GBA, have previously accepted category III (temporary) codes 0066T (Computed tomographic [CT] colonography [i.e., virtual colonoscopy]; screening) or 0067T (...diagnostic), as appropriate, and payable, coding options for VCs. Even then, however, you had to document a failed instrument colonoscopy to expect reimbursement for virtual colonoscopy claims.

The Medicare national coverage determination (NCD), described in the Internet Manual for Medicare National Coverage Determinations at (www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf, scroll to Section 220.1), states that local Medicare contractors have discretion to determine the specific circumstances under which they cover a CT scan. Therefore, some local Medicare contractors had developed local coverage determinations (LCDs) that addressed diagnostic CT colonography procedures.

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), said Palmettos 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.

New way: CMS has made it clear that Medicare will not pay your surgeon for virtual colonoscopies. While CMS stated that virtual colonoscopies may be a promising technology, CMS clearly states in its memo that the evidence is inadequate to conclude that CT colonography is an appropriate colorectal cancer screening test under § 1861(pp)(1) of the Social Security Act. CT colonography for colorectal cancer screening remains noncovered.

During the decision and comment periods, CMS cited concerns about radiation exposure, the need for follow-up colonoscopies to remove polyps, and the inability of CT scans to reliably detect small or flat growths.

The problem: There are some patients for whom, due to unique contraindications or other complications, this is the best, and sometimes only, diagnostic tool surgeons can use to perform colorectal cancer screenings.

Silver lining: Some private payers, such as Cigna and UnitedHealthcare, will pay you for virtual colonoscopies, so be sure to check with your individual payers about how, and if, you can report these procedures.

Experts Disagree on VC Use

Several professional associations announced their disagreement with the CMS decision. Make no mistake: If let stand, this CMS decision not to pay for CT colonography will cost lives, noted James H. Thrall, MD, chair of the American College of Radiologys board of chancellors in a prepared statement.

The American Cancer Society also lamented the CMS decision, stating that the lack of Medicare coverage for virtual colonoscopies limits the colorectal cancer screening options for patients. I am disappointed in this decision, as randomized clinical trials clearly show CT colonography (CTC) is as effective as optical colonoscopy for the early detection of early cancers and pre-malignant lesions. Medicare coverage for CTC, also known as virtual colonoscopy, would have provided an additional option for colorectal cancer screening, said Otis W. Brawley, MD, chief medical officer of the American Cancer Society.

The other side: Some associations disagree, however. The American Society of Gastroenterological Endoscopists supports the CMS decision. Many of the studies that support colonography were conducted on younger patients than Medicare recipients, ASGE President John L. Petrini, MD, FASGE, pointed out in a letter to CMS. Younger individuals have a lower prevalence of polyps, lower test-positive rates and lower rates of referral for optical colonoscopy with polypectomy, Petrini wrote.

More information: To read the decision memorandum,visit the CMS Web site at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=220.

Tackle Payment Woes With an ABN

Now that you know Medicare will never cover virtual colonoscopies, you should make obtaining an Advance beneficiary notice (ABN) for these procedures common practice. Youll need to append modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, it is not a contract benefit) because you know Medicare excludes the service.

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 know Medicare wont pay for the service and the patient must choose whether he is willing to receive the service knowing he will have to pay out of pocket.

Even though youll need an ABN form for virtual colonoscopy payments, dont use a blanket, or general, ABN. The ABN should describe the procedure and include an estimate of the cost the patient will incur. Have the patient sign and date the ABN, then give her a copy, and keep the original in your files. You then report 0066T and append GY.

Tip: If you fail to get a signed ABN, append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to let Medicare know youre aware that the carrier wont pay on the code, but you dont have a signed ABN on file.