Part B Insider (Multispecialty) Coding Alert

Published on Fri Oct 15, 2004 PDF

New policy making the procedure reimbursable in some cases could start a trend.

One payer has done a flip-flop that could mean more money in your pocket.

Empire Medicare Services reversed its 2003 position on virtual colonoscopy, also known as CT colonography. In October 2003, Empire said it wouldn't cover such procedures under any circumstances. But in a local coverage determination that took effect in mid-September, Empire said it would cover virtual colonoscopy in circumstances where a regular colonoscopy failed.

"Virtual colonoscopy is reimbursable only when performed following an instrument colonoscopy which was incomplete due to an obstructing lesion," says the Empire policy. "Tests performed without a prior incomplete colonoscopy in history may be reviewed and denied." Empire won't pay for virtual colonoscopy as a screening procedure. You'll have to document the failed "instrument colonoscopy" for any virtual colonoscopy claims.

Other carriers are on record as saying they won't ever cover virtual colonoscopies, including HealthNow NY (05/04) and CareFirst Blue Cross/Blue Shield of Maryland (09/03). But providers are hopeful the Empire policy will spark a reconsideration. Already, Cigna Healthcare has issued a draft LCD which duplicates Empire's, except that it refers to "fiberoptic colonoscopy" instead of "instrument colonoscopy." Starting in January, you can use 0066T and 0067T to bill for virtual colonoscopy.

"The approach they've described is appropriate," says Scottsdale, AZ physician Joel Brill. If there's a reason the patient failed to have a traditional colonoscopy and a virtual colonoscopy will aid in the management of the patient, then it seems fair to cover the test. But it shouldn't be the first choice at the moment.

The traditional fiberoptic colonoscopy has one significant advantage - if the physician finds something, she can deal with it at the time of the procedure. Medicare already pays for a number of screening procedures for colorectal cancer, including FOBT and fiberoptic colonoscopy.

There are all sorts of reasons a patient might not be able to complete a standard colonoscopy, including hemophilia and unusual pain, notes coding expert Jeff Fulkerson in Atlanta. But the medical community doesn't have a good enough handle on virtual colonoscopy to order it in place of a regular colonoscopy. Patients would certainly prefer a quick non-invasive scan that doesn't leave them sore afterward.