Part B Insider (Multispecialty) Coding Alert

Compliance:

CMS: Stop Reporting Diagnostic Colonoscopies for Screenings

Published on Mon Apr 11, 2016

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Plus: Nerve conduction studies and observation services are also under the agency’s magnifying glass.

Screening or diagnostic? The difference between these two words may be negligible to you—but that’s not how CMS feels. The agency is reminding practices that it’s inappropriate to report a diagnostic colonoscopy code to your insurer if the patient is in fact undergoing a service that’s considered “screening.”

According to the April 2016 Medicare Quarterly Provider Compliance Newsletter, CMS’s CERT contractors are reporting that they have seen this issue multiple times. In some cases, it’s the physician’s own documentation that reveals his error.

For example: “An internist billed HCPCS 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed [separate procedure]),” CMS notes in the Compliance Newsletter, which was released on Monday. “The submitted documentation included a signed and dated procedure report for the billed date of service. Documentation from the ordering/referring provider included the following statement: ‘The patient is here for screening colonoscopy. It has been 14 years since her last scope.’ The medical reviewer requested additional documentation from the billing provider and received a duplicate report without a pathology report. The submitted documentation supported a recode from 45378 to G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

In addition, CMS warns practices of the colonoscopy screening guidelines, which only cover a screening colonoscopy once every 24 months for high-risk patients and once every ten years for patients who aren’t high risk. In cases where the doctor finds a growth during a screening colonoscopy and subsequently performs a diagnostic procedure, he should bill the diagnostic colonoscopy code, as well as any biopsy removal, along with modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure) and should not report the screening code at all, the publication advises.

Keep Thorough Notes for Observation Care

CMS also issued a warning to practices that miscode observation care services, noting that auditors found rampant cases of missing or improper documentation for these codes (99217-99226) during the 2014 reporting period.

“For example, there was no order for observation services, no progress notes, or no physician’s signature on a progress note,” the Compliance Newsletter states. Therefore, if you report observation care services, be sure that your documentation includes orders, progress notes, dates, and signatures.

Nerve Conduction Studies Require Orders

CMS seemed to find fault with quite a few nerve conduction study (NCS) claims over the past few years, noting that insufficient documentation errors plagued these services in recent audits.

“Insufficient documentation means that something was missing from the medical records,” the agency said in its Compliance Newsletter. “For example, there was no order for the diagnostic test and/or no documentation of the intent to order the diagnostic test; no documentation of the medical necessity of the diagnostic test; and/or no physician’s signature on the report of the results.”

In addition, always make sure you report the most comprehensive nerve conduction study test rather than trying to report multiple tests together, which are often bundled. For instance, according to National Correct Coding Initiative (CCI) edits, you can’t bill both 95907 (Nerve conduction studies; 1-2 studies) and 95908 (Nerve conduction studies, 3-4 studies) because 95907 is bundled into 95908. Therefore, if you perform four studies, you’ll report just one unit of 95908 and you won’t bill any units of 95907.

Resource: To read the Aril 2016 Medicare Quarterly Compliance Newsletter, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909309.pdf.