Diagnostic EGD with Screening Colonoscopy

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Our anesthesiologist performed anesthesia for a patient who had a screening colonoscopy and at the same time - an EGD for abdominal pain. We billed the patient's insurance with 00740 dx code - R10.9 and the insurance processed the claim and left the patient with a copay/deductible. He called complaining that his account was coded wrong and we should have billed the screening colonoscopy so that his insurance will cover at 100%. Isn't that insurance fraud?? He claims to be a coder for this insurance company also...and says "just change it".

I have been scouring the internet, trying to find clear documentation that we coded this correctly (the facility and the surgeon's office also JUST billed the colonoscopy so their claims were paid 100% by insurance.) Is there anything else we should have done? From our end it seems we are doing it all correctly??!
 

CodingKing

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I'd be contacting the physician wondering why they are not billing separately for the EGD. You cant just pick and choose which to bill for, maybe just give an anonymous heads up to the payer.

However ignoring that, looking at the CMS Anesthesia Base units both 0740 & 0810 are the same at 5. So unless there is something I don't know (which is completely possible) are you able to use the 0810 instead of the 0740 and just add up the time units for both procedures like normal? Then primary dx could be the screening colonoscopy and the R code as secondary DX. Then that could leave it up to the payer to determine how they should apply the cost share keeping you out of it. Otherwise tell the patient to submit an appeal to his payer and that your billing is appropriate based off ASA guidelines.

You may also try calling the payer and ask for guidance on how they want you to handle routine and non-routine on the same DOS since you are now allowed to report 2 Anesthesia codes.

Of course it would be much easier if the rules allowed reporting of multiple ASA codes and the payer be responsible for disregard the base units of the lesser code.
 
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LisaAlonso23

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First, you billed correctly. You may only bill out for screenings when a pt is asymptomatic in that body system. This pt was experiencing abdominal pain, so billing for a screening colonoscopy would not be appropriate as this is in the same body system.

Secondly, you cannot bill out anesthesia separately for the EGD & colonoscopy that happened in the same time frame. For consecutive procedures, we code out each procedure, choose the anesthesia CPT code with the highest base units, and add the time together for the two procedures. The anesthesiologist only put the pt out once, therefore we bill once.
 
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