Wiki consultations for screening for colon cancer


East Haven, Connecticut
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My supervisor and I are once again having a debate about consultations with a diagnosis of screening for colon cancer. I am looking for educted opinions on this subject.

When a PCP sends a patient to our practice because the patient is now 51 years old and needs a screening colonoscopy can we bill a consultation? If our physician is seeing the patient at the Request of another physcian, and he is Rendering the service by perfoming the visit, and he is sending back a Report to the referring physician then haven't the 3 "R's" been met to qualify the visit as a consultation?

Also, our physician will be performing a colonoscopy, does this mean he can no longer bill the visit as a consultation? Does performing the procedure mean he is assuming care of the patient? Or does the fact that he is only doing the procedure and then referring the patient back to her PCP mean our physician is not "taking over the care" of the patient?

What does your practice do in these cases? Do you bill a consultation or a new patient visit? Or do you see the patient prior to the procedure for free, by not submitting the billing to the insurance company for the initial visit?
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If a patient is only needing a screening colonoscopy, it is my understanding that a pre-procedure visit is not warranted or payable (based on V76.51). I know it isn't for Medicare. Anyone else want to weigh in on this one? If the patient is being sent to the GI doc because of a "problem" (ie diarrhea) then a consult could be coded...
We do not bill consultations for these visits. The doctor is sending the patient to your practice to have a specific procedure performed. That is a referral not a consult. A consult would be if the patient is having diarrhea, abdominal pain, cramps, etc and your doctor is consulted as to how to treat the problem. Basically if the doctor knows why he is sending the patient to you it is a referral or transfer of care. If he has no idea what is going on and needs advice on how to treat the patient that is a consult.

I know this can be really confusing. I hope I have made it a little more clear for you.
I just wanted to comment on what Lisa said. She is correct. A visit prior to the colo should not even be billed. It is included in the procedure. Medicare is very adament about this and most other insurances won't pay for it either.
The AGA has published a standardized letter by Cecile Katzoff stating that there is no mechanism under CPT for billing for the visit preceeding a screening colonoscopy. CMS considers the visit part of the procedure and not seperately billable.

I hope this helps.

Anna Barnes, CPC, CGSCS
I just wanted to comment on what Lisa said. She is correct. A visit prior to the colo should not even be billed. It is included in the procedure. Medicare is very adament about this and most other insurances won't pay for it either.

Regarding this our office receives payment from most commercial insurances the two we don't receive payment from is Medicare and HealthNet. Which is why we have an ABN form for the Medicare patients. We are trying to solve the issue with the HealthNet claims, and currently appeal them, if anyone has a suggestion on that.
MGUEVARRA - According to all documentation that I have seen - the visit prior to the colo should not even be billed. It should be included in the colo. I understand that you may get paid -but I would make sure that you and your doctors understand that this may hurt you all in the long run if you are ever audited and if you are truly using the V7651 as your diagnosis code and getting paid. Just a suggestion.
Can you lead me to documented info regarding this? I hear that it is not a billable service but have nothing to back it up when bringing this to our doctors?
I just answered this question at work for someone a couple weeks ago. I am pasting my answer below.

"In regards to visits prior to a screening colonoscopy - If the pt is asymptomatic and has no medical issues managed by the gastroenterologist, then the service would not be considered medically necessary by Medicare. However, if the patient is symptomatic or has a medical condition that is managed during this visit, then it should be covered, according to these Medicare Guidelines below:

Preoperative Examinations.--For purposes of billing under the Physician Fee Schedule, medical preoperative examinations performed by, or at the request of, the attending surgeon does not fall within the statutory exclusion articulated in §1862(a)(7) of the Act. These examinations are payable if they are medically necessary (i.e., based on a determination of medical necessity under §1862(a)(1)(A) of the Act) and meet the documentation requirements of the service billed. Determination of the appropriate E/M code is based on the requirements of the specific type and level of visit or consultation the physician submits on his claim (e.g., established patient, new patient, consultation).

ICD Coding Requirements for Preoperative Services.--All claims for preoperative medical examination and preoperative diagnostic tests (i.e., preoperative medical evaluations) must be accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81 throughV72.84). Additional appropriate ICD-9 codes for the condition(s) that prompted surgery and for conditions that prompted the preoperative medical evaluation (if any), should also be documented on the claim. Other diagnoses and conditions affecting the patient may also be documented on the claim, if appropriate. The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81through V72.84).



Medicare coverage is permitted for services which are "reasonable and necessary for the diagnosis or treatment of illness or injury" by law (Title 18 of the Social Security Act 1862(a)(1)(A)) and therefore a precolonoscopy E&M which meets this requirement will normally be covered. An E&M visit which does not meet this reasonable and necessary standard is defined as noncovered by the law.


Even though Medicare may consider it not medically necessary if the pt has no symptoms or other conditions, most doctors agree that it is. I would recommend, rather than not billing it, explain to the patient it is necessary and ask them to sign an ABN. Here's a good article on that subject:

As far as other payors, without a specific policy saying you can not bill a pre-colonoscopy visit, then I would definitely bill for it. I might consider creating a general waiver form for all non-Medicare patients to sign. I did look on the BCBS of MA, Aetna, and Cigna websites in addition to posting the question on a couple listservs and searching the internet, and I can not find anything in writing any where regarding this subject for any other payor beside Medicare."

I hope that helps!!
:) Erica