Coding Clinic States use Z12.11 on High Risk Screening Colonoscopy???

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I reviewed documentation from a recent AskMueller seminar of GI coding and billing and it states to assign Z12.11 screening for malignant neoplasm as the primary diagnosis code for high risk screening colonoscopy, stating a surveillance colonoscopy is a screening colonoscopy. I had never heard this before so I started to do some research and found a different set of documents from another AskMueller seminar by a different trainer that states to only use Z12.11 on a high risk surveillance colonoscopy **IF** instructed by the payer policy. I've encountered several AHA/AHIMA posts that state the Coding Clinic recently recommended to use Z12.11 as the primary diagnosis code, but payers haven't changed their policies. This contradicts Medicare guidelines and the vast majority of commercial payer guidelines. Most state that once a history of polyps or cancer, all future screening colonoscopies are high risk (until you have no polyps detected and you are returned to the 10 year interval for screening) and to report the appropriate "history of" code as primary dx and use modifier 33 or PT if further polyps detected.

The AGA in their GI CPT updates review states that audits have begun and take backs are happening on charges billed as routine screening colonoscopy when signs, symptoms or disease are in the medical record (personal hx of colon cancer and/or polyps is a condition). Also, I'm also thinking of the logistics of reporting screening turned diagnostic with this change (if it truly is valid). Currently a commercial high risk colon for personal hx polyps that removes a tubular adenoma by snare is reported 45385, 33 Z86.010, D12.* ... it would now be reported as 45385, 33 Z12.11, Z86.010, D12.* ?? I've talked with many claims processors and a lot of clinical edits don't go beyond the primary dx. It would be perceived as a routine preventive colon, not high risk.

I'm just afraid that everyone will start throwing the Z12.11 on ALL colonoscopies and payers will pay, waiving patient out of pocket, then audits will ensue and take backs will be recouped and billing departments will need to chase patients for the out of pocket expenses (and these take backs can occur years after the original billing). A personal hx of polyps, cancer, colitis, etc. allows patients to have more frequent screenings which classifies them as not routine.

Any links to literature that you're aware of that is gold standard to support this change would be greatly appreciated. I did send a mesage to AskMueller to see if they could clarify their statement. I think payers should cover both routine and high risk colonoscopy 100% it's ridiculous the different interpretations from payer to payer and policy to policy within the same payer. Some BCBSMi policies cover any kind of colonoscopy once a year with no patient out of pocket and then some others are grandfathered and screenings of any kind are not a benefit.

Thanks in advance for any feedback!!
 

Mayzoo

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AAPC stance on Z12.11 (from a practicode rationale) is:

"Cannot code Z12.11 with this as patient has a previous history of cancer. Going forward, all future colonoscopies performed on this patient are considered surveillance, and is not longer eligible for screening colonoscopies."

Here a quite a few comments on Z12.11 from google. You will get a bunch of opinions that way.

https://www.google.com/search?ei=7SfRWoOgC4qKtQXuk5GYAg&q=guidelines+for+Z12.11&oq=guidelines+for+Z12.11&gs_l=psy-ab.3...4712.4712.0.5223.0.0.0.0.0.0.0.0..0.0....0...1.1.64.psy-ab..0.0.0....0.vRzo6PDQ2O8
 

thomas7331

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It's easy to get tangled up in the semantics of all this with terms like 'surveillance', 'high-risk', 'routine', etc. which are used inconsistently by coders and providers alike, and it becomes confusing when trying to translate these terms. I think it's best to keep this as simple possible: really there are only two categories here - screening and diagnostic.

By ICD-10 definition, a screening is "the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease... The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening." A history of polyps is not a sign or symptom, and is not an active disease, so this by itself does not make the colonoscopy diagnostic. It is one category of risk, which makes a more frequent screening recommended, but it does not change the fact that the service is still a screening. So I would agree with Coding Clinic on this that Z12.11 is still appropriate as a primary diagnosis. The history of polyps would just be additional information to signify to the payer that the screening meets the coverage requirements to be performed at the shorter intervals. Diagnostic colonoscopies are just for those patients with signs or symptoms that require the procedure to further investigate the cause.

'Surveillance' is a term which I think is misused often - I've seen it most often used for patients who have recently completed treatment for a malignancy and have not yet been declared in remission, and 'surveillance' is done to monitor to ensure the malignancy is not still present (which would be diagnostic, since it is part of the ongoing follow-up treatment for the malignancy). I don't think the term should be applicable to polyps since that is not a malignancy, or for diseases that are in remission, but providers do sometimes use the term this way and document that they are performing 'surveillance' to monitor for recurrence of polyps or cancers. I think this may be where a lot of the confusion comes from, but the important thing to remember is that 'surveillance' is not, in and of itself, a type of colonoscopy and is not necessarily a screening or a diagnostic.

Of course, as you point out, payers add to the confusion too by their own inconsistencies in how they interpret all this and how they want it reported. That's something we have limited control over, but I guess it does give us some job security.
 
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thx for input

I appreciate the input mayzoo and thomas7331. United Healthcare Policy Manual on colonoscopy states 'once polyps detected/removed all future colonoscopies are diagnostic' so there's still no consistency and it's quite the challenge to keep up with it and to explain to patients what to expect as their cost share. Good luck coders!
 

thomas7331

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Interesting.... I looked into this a little more after seeing your last post. The commercial guidelines for coverage of screening, of course, are governed by the new ACA requirements which require that plans must cover without cost-share the "evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF) with respect to the individual involved." If you look up the USPSTF recommendations on colorectal screening, there is a statement that "This recommendation applies to asymptomatic adults 50 years and older who are at average risk of colorectal cancer and who do not have a family history of known genetic disorders that predispose them to a high lifetime risk of colorectal cancer (such as Lynch syndrome or familial adenomatous polyposis), a personal history of inflammatory bowel disease, a previous adenomatous polyp, or previous colorectal cancer. When screening results in the diagnosis of colorectal adenomas or cancer, patients are followed up with a surveillance regimen, and recommendations for screening no longer apply. The USPSTF did not review or consider the evidence on the effectiveness of any particular surveillance regimen after diagnosis and removal of adenomatous polyps or colorectal cancer."

So I would say from this reading that commercial plans are probably within their rights to set coverage of colonoscopies for patients with a history of polyps, or those that fall outside the recommendations for other reasons, at a non-preventive benefit level, since the law only requires the full coverage for those things that are within the recommendations. But what's also interesting is that I don't see that they have said that a family history of polyps or cancer would make the procedure diagnostic, even though that risk factor also results in the same increased frequency of screening as does the personal history.

I just would point out though, that the USPSTF does not say that with a history or polyps, a colonoscopy is not a screening (again, a 'surveillance', which isn't defined in ICD-10) - they are only saying that these recommendations do not apply to patients with that history. And that said, from a purely coding standpoint, I think it is still appropriate based on ICD-10 directions to code the procedure as a screening if the patient is without signs or symptoms of disease at the time the test is ordered, even with a personal history. Others may see it differently, and we're splitting hairs a bit here, but I guess that's part of what makes coding so interesting.
 
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