Denied colonoscopy

Treetoad

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Hi all. I'm wondering if I could get an opinion with a problem that I find myself up against.

My doc took a Medicare patient to endoscopy for a screening colonoscopy. While in the suite, the patient mentioned that she was having a problem with "flat stools". My doc performed the colonoscopy and while there took ramdom biopsies. The pathology report came back negative. I charged procedure code 45380 with diagnosis V76.51 (screening, malignant neoplasm, colon) and 787.99 (symptoms, digestive system, NEC). I knew at the time that this was going to be a denied service, but I didn't see an alternative. When the denial finally came in, it was suggested to me (by a non-coder, but someone in the fiscal department) that I should have used diagnosis 564.9 (disorder, intestine, functional, NEC) and the claim would be paid. I don't want to label a person as having a functional intestinal problem when it doesn't appear they have one. The patient didn't sign an ABN. Also, did I mention the facility portion of the claim paid with the diagnosis that I gave it? Because of this, I'm being encouraged to use the functional diagnosis to get the provider portion paid. Does anyone out there know of anything that I could have done differently? I appreciate any thoughts.
 
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elenax

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I would code the 45380 with the 564.9, V76.51 or it could also be the 569.89, V76.51 IF the doctor operative report supports the 'flat stool' as the admiting diagnosis. I would also query the doctor with my concern and ask him to revise the report. If not, I guess you would have to write it off since there is no ABN on file.
 

shaanah

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The reason Medicare will not pay for the Colonoscopy with the V code is because with the V code you are showing that the patient was seen for a screening process and not a diagnostic procedure due to an acute illness. If the doctor saw the patient to 'screen' for possible malignancies you need to utilize the proper "G" code not the CPT 45380. Refer to the G0121 and G0105 and see if this may be closer to the type of service provided to the patient. Or if another procedure was also performed you may have to consider modifiers to show that seperate procedures were done on the same day. A good resource is MLN Matters through the CMS website. You can also view how Medicare dictates CCI edits for procedures like this and what CMS states as allowable ICD-9 specific codes. If under that CPT a DX is not listed you may be using an invalid code, or you may not have enough documentation to back up coding to that level. You may only resend your claim to Medicare as a reopening/redetermination if you decide the code should be different.

Hope this helps.
Shaana H :eek:
 

Treetoad

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I guess I was always under the impression that if the patient was having the colonoscopy for screening purposes, I was to used the applicable v-code for the diagnosis. And that if in the process of having the colonoscopy a separate diagnosis or symptom is discovered, I should use that additional diagnosis on the claim. Since the provider performed a biopsy, I cannot use the G-code as my procedure, as that is definitely a "screening only" procedure. Am I incorrect in my thinking? I've read this in several different publications.
 

elenax

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I agree with you Treetoad. I only use the 'G' code if the service performed is strictly a screening with no findings, biopsies or polyp removals.
 

Lisa Bledsoe

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When you submitted the claim, was your diagnosis order in box 21 V76.51 for the first dx and 787.99 for the second? And how did you link the dx codes on the line item? Medicare requires that if the patient was taken in for a screening colonoscopy that ended up with biopsies or polypectomy, the V76.51 be the first dx in box 21 but NOT linked on the line item - only link 787.99. That should get your claim paid without changing dx codes which really would not be appropriate just to get a claim paid.
Lisa:)
 
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