Straightforward Coding Guidance for
Published on Fri Mar 01, 2002
Family physicians (FPs) perform proctosigmoidoscopies (proctos) and flexible sigmoidoscopies (flex sigs) to examine a patients rectum and distal colon for screening, diagnosis or treatment of a problem. FP coders must know how to bill for these procedures when they are screenings, when theyre performed due to a patient complaint, and when they are discontinued.
To perform a proctosigmoidoscopy, the FP inserts a rigid endoscope in the rectum and sigmoid colon. A procto is usually performed because the patient exhibits symptoms such as bleeding (569.3) or rectal pain (569.42). A flex sig is the examination of the entire rectum, sigmoid colon and sometimes a portion of the descending colon with a flexible scope. A flex sig may be performed to identify a problem, but most often it is done as a diagnostic screening to check if the patient has colorectal (colon) cancer.
Coding the Diagnostic Screening
For correctly billing the flex sig when it is performed as a screening, accurate diagnosis coding is the key. Medicare covers colon cancer screenings via flex sigs once every four years for patients 50 years or older. For Medicare patients, use G0104 (Colorectal cancer screening; flexible sigmoidoscopy) with V76.51 (Special screening for malignant neoplasms; intestine; colon). Use 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and V76.51 to bill a screening flex sig to commercial carriers.
As a general rule, screening procedures have limited coverage by commercial insurance companies, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. Its important to know ahead of time if the patients insurance is going to pay so you can tell them if its a noncovered service before the procedure. Family practices should have commercial-insurance patients sign an advance beneficiary notice (ABN) before the procedure.
A screening exam is performed in the absence of patient complaints or symptoms. If, during the flex sig screening, the FP finds a problem, coders cannot change the diagnosis code. The initial V76.51 should be used whether or not the FP makes a definitive diagnosis. Its improper to use the physicians final diagnosis when coding for a screening, says Callaway. The diagnosis has to reflect that the patient is there for a screening, whether its paid or not. It cant be changed even if a problem is found.
Sometimes a screening can turn into another service. For example, during a screening flex sig the FP sees a polyp and takes a biopsy of it. In this instance, coders should use 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple). Use a corresponding diagnosis code to reflect the polyp (e.g., 211.3, Benign neoplasm of other parts of digestive system; colon), depending on its location. You [...]
