Wiki Back to 45378 vs. G0105

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KLRuhe

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I was just reading the posts from last week and it came really close to anwering a question I have. It stated that if there is a finding during a screening colonoscopy that CPT 45380 (for example) should be used with the screening diagnostic code first and the polyp (for example) diagnostic code second. This I understand.

However, the example screening code given (with finding) was V76.51. My question is: Is V12.72 considered a "screening" code. I believe it is. But my physicians and the endoscopy biller disagree. They believe if there was a previous finding that makes the patient "high risk" and that is why they are performing the colonoscopy, then V12.72 should not be considered "screening"and we should not have to follow Medicare guidelines for screening.
 
If the patient has a history of polyps (V12.72) but no current complaints, then V12.72 should be coded with G0105 as they are at high risk. V12.72 qualifies as the "screening" dx for G0105.
 
Quick question. Are you asking can the V12.72 code be used if the screening converted to a proc w/findings?

Like this example:

PT came in for a CCS high risk:

G0105 dx-V12.72

but there were findings so:

45380 dx 1 v12.72
dx 2 211.3

I believe the answer there would be no, you would still have to use the
V76.51, I'm not 100% on that though. But if you are asking can the V12.72 dx be used with the G0105? Big yes!!!!

Lisa, does the V12.72 still qualify as a screening code if it converts? I would think you would use the actual V code that demonstrates it was a colon screening (V76.51).

After speaking with a coworker of mine, she says she has seen different insurances want it different ways. Tricare for instance doesn't even want to see the conversion, either code it as a CCS or a diagnostic.

I'm now curious to see what others think.
 
coachlang3 said:
Quick question. Are you asking can the V12.72 code be used if the screening converted to a proc w/findings?

Like this example:

PT came in for a CCS high risk:

G0105 dx-V12.72

but there were findings so:

45380 dx 1 v12.72
dx 2 211.3

I believe the answer there would be no, you would still have to use the
V76.51, I'm not 100% on that though. But if you are asking can the V12.72 dx be used with the G0105? Big yes!!!!

Lisa, does the V12.72 still qualify as a screening code if it converts? I would think you would use the actual V code that demonstrates it was a colon screening (V76.51).
After speaking with a coworker of mine, she says she has seen different insurances want it different ways. Tricare for instance doesn't even want to see the conversion, either code it as a CCS or a diagnostic.

I'm now curious to see what others think.
Click to expand...

For Medicare ONLY I would use V12.72/G0105. Other carriers will need to see V76.51 as well as V12.72 (with 45378). MOST insurances are now requiring that the screening dx be on the claim, whether actually linked to the procedure or not (and of course depending on position i.e dx 1, 2, 3...) You need to show that it started out as a screening and became diagnostic.
 
I received a remittance advice from Medicare today where they made the following patient liability:

G0105 w/V12.72

Does that indicate that they consider the V12.72 screening?

The patient had a colonoscopy in '03 with a finding and so they're scheduled in 5 years. This time there was no treated finding.

Billers I work with believe that this should not be coded this way. They feel that V12.72 should be linked to 45378 because this is the follow-up of a problem. This would be utilizing LCD for Colonoscopy (link in response above).

My opion is that this is still a screening. But they are correct that my claim would fall into the colonoscopy LCD coding guidelines using 45378 w/V12.72.

Thanks for input.

Kay Ruhe, CPC, CCS-P
 
No, if the patient came in for a screening the proc code would be G0105 and V12.72. The pt is high risk (G0105) due to previous findings (V12.72). The only time you would need to code the 45378 would be if the patient presented with current symptoms but there were no findings. This is for Medicare. However, other insurances don't like the G codes so you would need to use the 45378.
 
schweppeme said:
I received a remittance advice from Medicare today where they made the following patient liability:

G0105 w/V12.72

Does that indicate that they consider the V12.72 screening?

The patient had a colonoscopy in '03 with a finding and so they're scheduled in 5 years. This time there was no treated finding.

Billers I work with believe that this should not be coded this way. They feel that V12.72 should be linked to 45378 because this is the follow-up of a problem. This would be utilizing LCD for Colonoscopy (link in response above).

My opion is that this is still a screening. But they are correct that my claim would fall into the colonoscopy LCD coding guidelines using 45378 w/V12.72.

Thanks for input.

Kay Ruhe, CPC, CCS-P
Click to expand...

There are guidelines as to how frequently the patient can have the procedure. Off the top of my head I'm thinking 10 years for non-high risk and 2 years for high risk. So if it's been less than 2 years since the last colonoscopy (for the high risk patient) then Medicare is not going to cover it.
 
coachlang3 said:
No, if the patient came in for a screening the proc code would be G0105 and V12.72. The pt is high risk (G0105) due to previous findings (V12.72). The only time you would need to code the 45378 would be if the patient presented with current symptoms but there were no findings. This is for Medicare. However, other insurances don't like the G codes so you would need to use the 45378.
Click to expand...

i agree with this from coachlang.....and also, medicare will not pay for the screening G0105 when billed/coded with the V76.51, we have been getting plenty of denials for medical necessity but they will pay for the V12.72 along with the V10.05, V10.06 and V16.0....there are limited V-codes that warrant payment from medicare.

And yes, G codes are only for Medicare...other ins will need to be billed the 45378
 
What if

Very often I have pt's that have their colonoscopies for screenings, and the only finding is diverticulosis w/out hemorrhage (not a covered dx). Is this still a screening since the dx isn't a covered one and what code would i use?
 
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