Medicare Compliance & Reimbursement

Once a screening, always a screening, CMS says The Centers for Medicare & Medicaid Services (CMS) has clarified that if a physician finds a polyp or other abnormality during a screening colonoscopy, you should nevertheless cite the screening V-code diagnosis as primary. In fact, even if the physician removes the polyp, the exam remains a "screening" under ICD-9 guidelines. "This new CMS directive is a relief," says Heather Corcoran, coding manager at CGH Billing in Louisville, KY. "The issue of how to report a 'screening-turned-diagnostic' has confused a lot of practices, so a clarification was badly needed." 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. Pick your dx: You will assign a V code as the primary diagnosis with any screening colonoscopy. For low-risk patients, you should cite V76.51 (Special screening for malignant neoplasms; colon). When reporting G0105, however, you must supply evidence to support the patient's high-risk status. Some diagnoses that Medicare considers high-risk factors for colorectal cancer, and therefore justify a high-risk screening, include V10.05 (Personal history of malignant neoplasm; large intestine), V12.72 (Personal history of colonic polyps), and V16.0 (Family history of malignant neoplasm; GI tract). When a screening exam uncovers a polyp, you will turn away from the G codes to report the procedure, and instead select an appropriate category I CPT code. Example: The physician begins a screening colonoscopy for an average-risk Medicare patient. She then finds a polyp, which she biopsies. In this scenario, you should choose 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple), without any modifiers, rather than G0121. In other words: If, during the screening colonoscopy, the physician detects a lesion or growth that results in a biopsy or removal of the growth, you should bill -- and be paid for -- the appropriate diagnostic procedure (45380) rather than G0121. An important point to remember, however -- and the subject of the recent CMS clarification -- is that you should retain the initial V code as the primary diagnosis, even if the physician finds a polyp and performs a diagnostic colonoscopy during the screening exam. "Whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination," states Medicare Learning Network (MLN) Matters article SE0746, "Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscopy." This scenario assumes that [...]