Part B Insider (Multispecialty) Coding Alert

Published on Sat Jul 22, 2006 PDF

Medicare carriers' instructions are 'against HIPAA,' official warns

The Part B carriers and the ICD-9 coding experts are stuck in a tug-of-war over colonoscopy coding--and they-re using your claims as the rope.

Conflict: Almost all carriers are now instructing you to switch to the polyp diagnosis code if your physician finds a polyp during a screening colonoscopy. That's the easiest way to get paid for a polypectomy, say coders. But the National Center for Health Statistics, which generates ICD-9 codes, stands by its rules requiring you to list the screening -V- code as the first diagnosis code.

-Official coding guidelines do require that if a patient is having health care encounters specifically for a screening, that does need to be the first listed diagnosis,- says Amy Blum, medical classification specialist with the NCHS. If your physician finds a polyp during a screening colonoscopy, you should list the polyp diagnosis code second, but keep the screening -V- code as the first code, she urges.

-These are the official guidelines and insurers are required under HIPAA to follow these guidelines,- Blum insists. -We are not planning to change the guidelines.- If Medicare or other payors don't follow the guidelines, they-re acting -against HIPAA,- she adds.

By contrast, Part B carrier Noridian issued instructions telling you to list -the ICD-9-CM diagnosis code that reflects the finding that required the therapeutic procedure- as the first code. You can list the screening code second, the carrier adds.

One carrier, TrailBlazer, has told providers it will accept claims either way, says Quinten Buechner, a consultant with ProActive Consulting in Cumberland, WI.

The American Gastroenterology Association is aware of this issue and is working to clarify it with the Centers for Medicare & Medicaid Services, according to a spokesperson.

Most providers say they-re using the polyp diagnosis as the first diagnosis code, because the carriers will pay for it. -I don't see how you could ever get it paid- the other way, says Cindy Kerstetter, a coder with Atlanta Gastroenterology Associates in Georgia.

Some carriers won't even recognize a secondary diagnosis code on a claim, says Chris Felthauser, medical coding instructor with Orion Medical Services in Eugene, OR. All diagnosis codes must be linked directly to procedure codes, or the carrier's computer system rejects them, Felthauser says.

Warning: The HHS Office of Inspector General can go back four years in auditing your files, and the OIG doesn't care what the carriers instruct, warns Buechner. If you bill for a screening colonoscopy with polypectomy and don't list the screening diagnosis first, the OIG could regard those bills as false claims.

What you should do: Get your carrier's guidance in writing. Some carriers have already put out written guidance advising you to list the polyp code first, but you should make sure your carrier has done so. That should at least protect you from fines and penalties if the OIG goes after you, and possibly allow you to resubmit the claims if they-re overturned later, Buechner advises.