Colonoscopy ?screening

GLORIAR

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My question is regarding diagnotic coding for a colononscopy in an ASC. Example: Patient came in for a screening but physician found a polyp which was removed. Would you code screening V76.51 as 1st diagnosis or the polyp 211.3?
 

mbort

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The V76.51 would stand true for Medicare however medicare rules are different than those stated in the ICD-9 book for ASC's.

Unless I have something in writing from a carrier, I follow the instructions for ASC's in the ICD-9 book under Section 4 Letter O.

hope this helps
Mary, CPC, COSC
 

mitchellde

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The coding guidelines actually set this for us and they are not Medicare guidelines they are the official guidelines for coding and reporting. They state that if the reason for he visit is screening then screening remains the first-listed dx code regardless of the findings or subsequent procedure performed at that setting. So the first-listed code is screening then polyps. Also the coding clinics have addressed this many time. This does not depend on payer, it has to do with why was the patient there, and they were there for screening. The polyps are an incidental finding.
 

mbort

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The coding guidelines actually set this for us and they are not Medicare guidelines they are the official guidelines for coding and reporting. They state that if the reason for he visit is screening then screening remains the first-listed dx code regardless of the findings or subsequent procedure performed at that setting. So the first-listed code is screening then polyps. Also the coding clinics have addressed this many time. This does not depend on payer, it has to do with why was the patient there, and they were there for screening. The polyps are an incidental finding.
I believe you are referring to guidelines for physicians.

ASC's have different guidelines than physicians/surgeons offices. I stated in my previous post above specifically where you can find them in the ICD-9 Book which are the "official guidelines".

The guidelines for ASC's state:
"For ambulatory surgery, code the diagnosis for which the surgery was performed. If the post-operative diagnosis is known to be different from the pre-operative diagnosis at the time the diagnois is confirmed, select the POST-OPERATIVE diagnosis for coding since it is the most definitive."

straight from the ICD-9 book-Section IV Letter O (page 25 of my book)

Hope this helps,

Mary, CPC, COSC
 

mitchellde

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That is for surgery and I agree but that piece of the guideline does not address screening which is different. ASC does not have a different guideline for screening.
 

mbort

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I suppose we will have to agree to disagree on this one. Since the guidelines are not specific and the CPT codes are almost all considered "surgery", this is the rule I follow, this is the rule I appeal with. If I do not have something in writing from a carrier that directs me to do something different, this is the rule I follow.

As we all know, coding can be very challenging and everyone sees and interprets things differently.

Mary, CPC, COSC
 

mitchellde

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I am not sure which guidelines you are referring to but there is only one set of official guidelines. The following is an excerpt from these guidelines:

The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.
The guidelines are organized into sections. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Section II includes guidelines for selection of principal diagnosis for non-outpatient settings. Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for outpatient coding and reporting.
From Section I under screening it says:
Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.
The V code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.
And from section III
L.
Patients receiving diagnostic services only
For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
And finally:
In determining the first-listed diagnosis the coding conventions of ICD-9-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.

So I do not see how there is any way to disagree on this one.. clearly the screening code is first listed regardless of setting.
 

GLORIAR

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Thank you this confirms what I have been doing based on my knowledge.

I believe you are referring to guidelines for physicians.

ASC's have different guidelines than physicians/surgeons offices. I stated in my previous post above specifically where you can find them in the ICD-9 Book which are the "official guidelines".

The guidelines for ASC's state:
"For ambulatory surgery, code the diagnosis for which the surgery was performed. If the post-operative diagnosis is known to be different from the pre-operative diagnosis at the time the diagnois is confirmed, select the POST-OPERATIVE diagnosis for coding since it is the most definitive."

straight from the ICD-9 book-Section IV Letter O (page 25 of my book)

Hope this helps,

Mary, CPC, COSC
Thank you this confirms what I have been doing based on my knowledge. We have read the Ambulatory Coding & Payment Report Vol 13 No. 1 pg 1-3 which dicusses this same topic giving warnings if you do or don't code screening primary. In the end the issue remains unrelolved since AMA, AHA and CMS don't even agree.
 

LTibbetts

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I am not sure which guidelines you are referring to but there is only one set of official guidelines. The following is an excerpt from these guidelines:

From Section I under screening it says:
Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.

Not to get into the middle of this one, because I do believe that each opinion is validated, but doesn't the "may be" in that quote from the guidelines constitute a decision by the coder to do so? It doesn't seem like it is mandated in that statement. For us here, we use the V code for Medicare and BX but for everyone else, we use the 211.3 code. I am not trying to make waves, I am legitamitely confused by all of this. Do you follow the "surgery" guidelines or do you follow the "screening" guidelines? We are also CAH so our case proably doesn't apply to all.

In the end, I guess I also agree with Gloria that since even the "big wigs" can't agree, we do what we have to, individually, to code what we believe to be "to the best of our ability".
 

mitchellde

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I disagree, I feel the guidelines are very clear on the subject of screening. My question is why code it different for different payers? This says you are coding for reimbursement then. The scenario did not change just becuse the payer changed. The guidelines state:
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. In these cases, the sign or symptom is used to explain the reason for the test.
A screening code may be a first listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems. A screening code is not necessary if the screening is inherent to a routine examination, such as a pap smear done during a routine pelvic examination.

Also Coding clinics state:
Whne the reason for the encounter is screening, then screening remains the first-listed code regardless of the findings or any additional procedure performed due to the findings.

If a patient does not have screening as a benefit then they are responsible for the payment. However if they do have screening benefits and you code it as a diagnostic exam, then they will most likely have out of pocket expenses like deductible that would not have incurred. I have seen this happen numerous times and then try to unravel it on the back end (no pun intended) is very time consuming.

So my point being if it is screening for a Medicaid patient then with the same scenario it is screening for everyone.
 

LTibbetts

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I definitely see your point! As far as coding differently for different payers, I couldn't agree more. I am walking a very fine line here by doing that. Trying to explain that to my supervisors, however, is another issue completely. But anyway, thanks for the clarification, Deb. Maybe I can use it as ammo with management here. Have a good day:)
 
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