Part B Insider (Multispecialty) Coding Alert

Published on Mon Jun 19, 2006 PDF

Include the screening "V" code, but not in the primary position

Don't let confusion over the rules for diagnostic colonoscopies jeopardize your rightful reimbursement.

Many coders don't know what to do when a physician is performing a screening colonoscopy and finds a polyp or other problem. They risk denials if they bill for a diagnostic colonoscopy using a screening ICD-9 code, say experts. Centers for Medicare & Medicaid Services officials muddied the waters last month when they said you should still bill for a screening colonoscopy even after finding a polyp. (See PBI, Vol. 7, No. 4.)

Clarification: Now CMS officials set the record straight. "The policy is that if you find a polyp and remove it, you change to the diagnostic code," explains William Rogers, a physician who heads the Physician Regulatory Issues Team at CMS. But you can still use the "V" code to indicate that the colonoscopy was a screening colonoscopy.

"There's been no change in the policy," Rogers adds. Once you find a polyp, the patient is automatically at high-risk for colon disease, and can have screenings more often, he adds. Also, if the physician feels the need to give the patient another colonoscopy, it'll automatically be diagnostic, like a mammogram after a breast tumor.

Watch your ICD-9 codes: Once the physician finds a polyp, you should no longer use a screening "V" code as the primary diagnosis code, warns Carol Pohlig, a coder with the Department of Medicine at the Hospital of the University of Pennsylvania. You should list the polyp as the primary diagnosis, especially if the physician performs a biopsy.

Remember: A physician would never perform a biopsy as part of a screening procedure, Pohlig says. The only exception would be if the patient had colitis and the physician was doing a biopsy for surveillance purposes.

Cause of confusion: Many coders become confused because the rules are different for radiological procedures and some other diagnostic tests, says Pohlig. With a radiological procedure for screening purposes, if you find something, you would still bill for a screening test, and report your findings in the secondary position.

But a screening colonoscopy converts to a diagnostic one if the physician finds a serious problem.

Note: If the physician finds a less serious problem, like diverticulosis or hemorrhoids, then the screening colonoscopy should remain a screening test, notes Pohlig. The patient might qualify as high-risk and receive screening colonoscopies more often, however.