General Surgery Coding Alert

Question: We had a patient who underwent a “high risk” colonoscopy screening for personal history of colon cancer. The surgeon found no abnormalities and took no biopsies during the procedure, so we billed 45378 with the ordering diagnosis V10.05. However, this payer will only recognize V76.51 for screening colonoscopy, so the patient’s diagnostic benefits were applied, engendering large out-of-pocket expenses. How can we code this scenario to utilize the patient’s screening colonoscopy benefits?

Utah Subscriber

Answer: If you’re billing Medicare, you should report the procedure as a high risk screening with code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). Then, report V10.05 (Personal history of malignant neoplasm of large intestine) as the primary diagnosis.

Code V10.05 fits the bill for primary diagnosis because the patient presents for a screening exam and not specifically for follow-up evaluation of the cancer. If the encounter’s purpose is for cancer surveillance and follow-up at an interval close to the surgical treatment, you could instead code V67.09 (Follow-up examination following other surgery) as your primary diagnosis although this ICD-9 code is not frequently used.

On the other hand, some commercial carriers would require the code 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) with modifier 33 (Preventive services) and V10.05 as the diagnosis.

“CPT® modifier 33 has been created to allow providers to identify to insurance payers and providers that the service was preventive under the applicable laws, and that patient cost-sharing does not apply,” according to AMA. This means that a patient’s co-insurance, co-payment, and deductible are waived for the applicable services (in this case, 45378). All commercial carriers and Medicare payers should be in compliance with these rules as established in the Accountable Care Act (Obamacare).

List V10.05 as your primary diagnosis for both circumstances (Medicare and commercial payers), whether the colonoscopy findings were clear or not. Don’t report a cancer code (153.3, Malignant neoplasm of sigmoid colon) or the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract) or a screening code (V76.51, Special screening for malignant neoplasms colon) as the primary diagnosis in this case.