Wiki Colonoscopies: screening vs. diagnostic

[kimberliterpstra]

Is anyone able to provide a good resource for information on this? I am new to billing these for a colorectal surgeon and could use some solid guidance. Patients are upset because they thought they were going in for a screening and because a polyp, etc. is found, it changes to a diagnostic procedure and therefore their insurance doesn't pay the same benefit (more $ they have to pay). I have a primary care physician coming at me, telling me I need to change the way we code it because the "intent" was for a screening and that's the way it should be billed. I disagree, because from what I've been told, once "something" is found and it's biopsied, it changes from a screening to a diagnostic.
Any information would be appreciated!

 

[mitchellde]

The coding guidelines cover this. When an asymptomatic patient presents for screening then the screening V code remains the first listed dx code and the finding which is incidental is secondary. You code then the procedure code of say polypectomy with a 33 modifier. Your provider is correct. A screening never changes from screening, it remains screening but may INCLUDE a diagnostic due to incidental findings. If a patient is symptomatic and the provider upon the study renders a definitive diagnosis then the diagnosis changes from the symptom to the finding, since the finding was what was being sought.

 

[Karen8084]

screening vs diagnostic

That is correct that you would add the modifier "33" when a screening is performed and a polyp is found. However, the 33 is only for commercial carriers. You would add the modifier "PT" for medicare patients. This is, and always will be a matter of contention for GI practices, however, most carriers now will allow screening colonoscopies and cover at 100%. Patients are urged to check their benefits, prior to the procedures. But be sure to list the screening diagnosis, V76.51, first on the claim, even if a polyp is found, that should be the secondary diagnosis.

 

[chembree]

Of course this goes with what the previous posters stated:

CMS advises that, whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination.
http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/SE0746.pdf

Providers should append modifier PT (CRC screening test converted to diagnostic test or other procedure) to the diagnostic procedure code that is reported when the screening colonoscopy or flexible sigmoidoscopy becomes a diagnostic service. The claims processing system will respond to the modifier by waiving the deductible for all surgical services on the same date as the diagnostic test.
http://www.gastro.org/journals-publ...l-practice/cms-issues-guidance-on-pt-modifier

CPT modifier 33
has been created to allow providers to identify to insurance
payers and providers that the service was preventive
under applicable laws, and that patient cost-sharing does
not apply. This modifier assists in the identification of
preventive services in payer-processing-systems to indicate
where it is appropriate to waive the deductible associated
with copay or coinsurance and may be used when a service
was initiated as a preventive service, which then resulted
in a conversion to a therapeutic service. The most notable
example of this is screening colonoscopy (code 45378),
which results in a polypectomy (code 45383).
http://www.ama-assn.org/resources/doc/cpt/new-cpt-modifier-for-preventive-services.pdf