Pathology/Lab Coding Alert

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.
Question: We received a colon biopsy specimen for evaluation (88305), with the ordering physician listing the reason for the test as signs, symptoms and history of disease. However, when we reported the diagnosis codes given to the lab (787.99, change in bowel habits, and V16.8), Medicare would not pay for the service. What is the correct coding for this situation?

California Subscriber
              Answer: Based on V16.8 (family history of colon cancer), Medicare may have interpreted this as a screening test. But because the test was ordered based on signs and symptoms of disease, it is not a screening service. The pathologist should report the pathologic findings as the diagnosis when billing the biopsy service.
 
For example, the diagnosis might be reported with 211.3 (benign neoplasm of colon) or 153.6 (malignant neoplasm of ascending colon), depending on the pathologist's findings. According to Medicare policy, failure to submit an ICD-9 code at its highest level of specificity will result in claim denial.
 
If the results of the pathologist's examination are normal, the most specific diagnostic information should be used based on presenting signs and symptoms. If the claim is not covered based on 787.99, you might call the ordering physician to see if more specific information is available about the bowel habit change. For example, if the patient exhibited functional diarrhea, you could report 564.5, which may be covered depending on the carrier.