History of Colon Polyps question

Lindseywingate1990

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When coding a colonoscopy and the indications for the colonoscopy state

"the patient is 66 year old female with history of colon polyps, who presents for re-evaluation by colonoscopy.'' the colonoscopy was performed and three small flat polyps were found and removed by hot biopsy forcepts in the rectm

i know this is coded V12.72 but my question is would this be considered a screening and if not polyps were found would i code the G code? or is this just considered followup for polyps and not considered a screening?

should i code

1. V12.72
2. 211.4 rectal polyp

1. 45384-PT DX: 1 2
 

WROGERS

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You have the correct coding listed. You would not use the G code because it turned from a screening to a diagnostic. Use of the PT modifier tells Medicare the patient was scheduled for a screening but polyps were removed. Once a patient has polyps they will always have V12.72.

45384-PT (link 211.4 to this code)
V12.72
211.4
 

btadlock1

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When coding a colonoscopy and the indications for the colonoscopy state

"the patient is 66 year old female with history of colon polyps, who presents for re-evaluation by colonoscopy.'' the colonoscopy was performed and three small flat polyps were found and removed by hot biopsy forcepts in the rectm

i know this is coded V12.72 but my question is would this be considered a screening and if not polyps were found would i code the G code? or is this just considered followup for polyps and not considered a screening?

should i code

1. V12.72
2. 211.4 rectal polyp

1. 45384-PT DX: 1 2
Your diagnoses are backwards - once more polyps were found and removed, the colonoscopy went from "screening" to "surgical" - you code the results, before the indication. Make 211.4 you PDx, and V12.72 secondary, and you'll be good to go! ;)
 

Lindseywingate1990

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if i dont put the V code first Medicare will process it not as a screening which will make the patient have more of a coinsurance or deductible right? i have always been told to put the V codes first because it effects the way medicare pays and if the patient came in for a screening and happend to find polyps it would still need to be processed as a screeing because that is what the patient came in for right? thanks for your help i really appreciate it.
 

btadlock1

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if i dont put the V code first Medicare will process it not as a screening which will make the patient have more of a coinsurance or deductible right? i have always been told to put the V codes first because it effects the way medicare pays and if the patient came in for a screening and happend to find polyps it would still need to be processed as a screeing because that is what the patient came in for right? thanks for your help i really appreciate it.
Never base your code selection on how it affects payment - that's playing with fire. I can't remember if Medicare accepts the 33 modifier or not, but if they do, use it on this. It has to be coded based on what happened, no matter what. If I remember correctly, the provisions of PPACA allow for pt cost sharing to be treated like a screening, even when it turns into surgical. If you're still not sure, call and ask your MAC. Better to be safe, than sorry. ;)
 

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Actually the V code would be in the first position regardless of payment reasons. You show the why (it was done) followed by the what (was found) in the case of screenings. It's in the guidelines of ICD-9 uder the screenings section.
 

btadlock1

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Actually the V code would be in the first position regardless of payment reasons. You show the why (it was done) followed by the what (was found) in the case of screenings. It's in the guidelines of ICD-9 uder the screenings section.
Had she been using a special screening V-code (eg, V73 - V82), then you would be absolutely correct; however, the guidelines for screening aren't applicable to 'personal history' codes, such as V12.72. Before PPACA, it may have been necessary to list the history code as primary, to show an indication for the screening; but once the procedure became surgical, and changed from being reported with a G-code, to the surgical procedure described by a CPT code, it wouldn't be appropriate to list a personal history V-code as the primary diagnosis anymore. For one, it would be a mismatch to the procedure (You can't have a polypectomy done for screening purpuses - it's done, because there were actually polyps - as in 211.4).
 
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pamsbill

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Except in the gastro world the commercial insurances will not apply the patient's screening benefit which 90% of policies allow unless you use that V code in the primary position. I know you say not to code for payment reasons but screening colonoscopies and commercial insurances are a completely different animal.


PJM
 

btadlock1

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Except in the gastro world the commercial insurances will not apply the patient's screening benefit which 90% of policies allow unless you use that V code in the primary position. I know you say not to code for payment reasons but screening colonoscopies and commercial insurances are a completely different animal.


PJM
My background is in commercial claims - I'm perfectly aware of how they operate; my assertion is still the same:
You do not code based on payment. Ever. Although it's true that you probably won't face fraud penalties for improperly billing commercial payers (as they are not within the OIG's jurisdiction), your provider could still be sued for breach of contract, receive payment delays due to pre-payment holds on all of their claims, and possibly lose their contract with those payers.

You absolutely must follow ICD-9 guidelines, when submitting claims. Coding based on reimbursement is especially dangerous, when Medicare, Medicaid, Tricare, or any other governmental payer is involved - it's considered fraud. If you don't look good in an orange jumpsuit, I would advise against the practice.

http://codingnews.inhealthcare.com/...which-diagnosis-code-will-get-my-claim-paid’/
"“It is illegal to just assign an ICD-9 code that will get your claim paid — you have to report the codes documented in the record,” says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. Any diagnosis that you report on a claim must be clearly documented in the patient’s chart — not selected because it’s a covered diagnosis."

If you're concerned about the cost for the patient, keep in mind, that the provider has discretion in providing discounts - especially for commercial payers. But as I mentioned before, cost sharing obligations are not an issue, in this type of situation - the Affordable Care Act made it illegal for insurers to charge copays and deductibles for preventive services, even when they are converted into therapeutic services, mid-surgery. That's what the 33 modifier is for (for commercial payers only - again, you would use modifier PT for Medicare)...

http://www.ama-assn.org/resources/doc/cpt/new-cpt-modifier-for-preventive-services.pdf
"In response to this PPACA requirement, 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).
"
 
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btadlock1

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Technically, you should be using V76.51, before V12.72, anyways, for Medicare - As mentioned by coachlang3, that will be the primary diagnosis, regardless of the findings.;)
 

Lindseywingate1990

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I understand exactly what you are saying i guess more of my question is when a patient comes in that doesnt state the patient came in for a screening it say "history of polyps" but does not state the patient has any symtoms or complications should i count this as a screening and add the -PT or -33 modifier like this


1. 211.4
2. V12.72

1. 45384-PT?




thanks for all your input
 

pamsbill

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I totally agree with you with regard to improper coding and penalties for such. I spend my whole life making sure no one does anything fraudulent. However with these screening colonoscopy benefits we have had numerous insurance companies call us (because the patients call them) and tell us to submit corrected claims with the "V" code in the primary position. Additionally (and to throw in yet another twist) these insurances do not recognize V12.72 as a screening so you have to put the V76.51 as primary. A well-known auditor we use, one I am sure you know, told me she did not see a problem with using the V76.51 in the primary position and the V12.72 in the secondary position because a patient who presents with a personal history of polyps has no active symptoms.


1. A patient is seen in the outpatient clinic for colonoscopy due to family history of colon cancer. The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. The colonoscopy revealed a colonic polyp that was removed by snare technique. How should the diagnoses and CPT procedures for this case be coded?


1. Assign code V76.51, Special screening for malignant neoplasms, colon, as the first-listed diagnosis because this was a screening colonoscopy. Code V16.0, Family history of malignant neoplasm, gastrointestinal tract, may be assigned as an additional diagnosis. Assign code 211.3, Benign neoplasm of colon as an additional diagnosis. Because the polyp was removed, 45385 is reported to identify the definitive procedure performed.

This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.

 
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pamsbill

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I understand exactly what you are saying i guess more of my question is when a patient comes in that doesnt state the patient came in for a screening it say "history of polyps" but does not state the patient has any symtoms or complications should i count this as a screening and add the -PT or -33 modifier like this


1. 211.4
2. V12.72

1. 45384-PT?




thanks for all your input
I am assuming you are asking about a Medicare patient since you are assigning the "PT" modifier. For a Medicare patient I would code:

1. V12.72
2. 211.4

45384

You do not have to use the PT modifier because Medicare already recognizes the V12.72 as a high-risk screening.

PJM
 

coachlang3

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In the regards of what is documented:

If you feel it warrants it, send the note/charge ticket back to the doctor to verify a screening and then add an addendum to the dictated note that the patient is here for a screening due to personal or family history and is currently clear of gi symptoms.

If your doctor does not dictate that the purpose of the procedure is a screening and the patient is clear if gi symptoms, than a good auditor could have a field day with that note. Not saying they would, just that they could.
 

coachlang3

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I am assuming you are asking about a Medicare patient since you are assigning the "PT" modifier. For a Medicare patient I would code:

1. V12.72
2. 211.4

45384

You do not have to use the PT modifier because Medicare already recognizes the V12.72 as a high-risk screening.

PJM
Yes, you do still need the PT modifier unless the CPT code you are using is one of the G codes. The PT modifier shows the service started out as a screening (G0105) and turned diagnostic (45384).

The V12.72 does not show it as a screening, only that the patient has a history of polyps which is a "reason" for a high risk screening.

This is why the PT and 33 mods were created.
 

pamsbill

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Yes, you do still need the PT modifier unless the CPT code you are using is one of the G codes. The PT modifier shows the service started out as a screening (G0105) and turned diagnostic (45384).

The V12.72 does not show it as a screening, only that the patient has a history of polyps which is a "reason" for a high risk screening.

This is why the PT and 33 mods were created.
Coachlang is correct - so sorry. I was wr... I was mistaken!
 

btadlock1

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It should be coded as 45384-PT
Diagnoses:
1.V76.51
2.V12.72 (although it's not really necessary, since polyps were discovered)
3. 211.4

Under no circumstances, would you use V12.72 as the primary diagnosis - it's an "FYI" code; not a reason for doing anything.
 

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It should be coded as 45384-PT
Diagnoses:
1.V76.51
2.V12.72 (although it's not really necessary, since polyps were discovered)
3. 211.4

Under no circumstances, would you use V12.72 as the primary diagnosis - it's an "FYI" code; not a reason for doing anything.
I disagree Brandi. If no polyps had been found then V12.72 would be your primary diagnosis and your procedure code would be G0105. At least that is what I do with no issues.
 

btadlock1

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I disagree Brandi. If no polyps had been found then V12.72 would be your primary diagnosis and your procedure code would be G0105. At least that is what I do with no issues.
Just because you don't have 'issues', doesn't make it correct - ICD-9 guidelines state:
"List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided...", and
"....history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment."

There are a lot of articles on the subject, also:

http://health-information.advanceweb.com/Features/Articles/Coding-Colonoscopies.aspx
"There are specific criteria that the Centers for Medicare and Medicaid Services (CMS) requires for a patient to be categorized as "high risk." To establish the patient as "high risk," the patient should exhibit one or more of the conditions found on the CMS list, which you should report as a secondary diagnosis to V76.51. Here are some examples:

•V10.05-Personal history of malignant neoplasm, large intestine
•V12.72-Personal history of colonic polyps "

http://www.surgistrategies.com/articles/2008/11/colonoscopy-billing.aspx
"Medicare has slightly different code selections for colorectal screenings. Let’s talk about the ICD-9 code selections. For a Medicare patient, you would report V76.51 as the primary diagnosis. Then you must check if the patient is considered a high risk. There are specific criteria that CMS requires for a patient to be categorized as “high risk.” To establish the patient as “high risk,” the patient should exhibit one or more of the conditions found on the CMS list, which you should report as a secondary diagnosis to V76.51. Here are some examples:

V10.05—Personal history of malignant neoplasm, large intestine
V12.72—Personal history of colonic polyps "

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/SE0746.pdf
"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."
 
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scorrado

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The "Guide to Medicare Preventative Services" does not say anything about using V76.51 as the primary dx for a high risk screening. On page 80 it states " However, when billing for the high risk beneficiary, the screening diagnosis code on the claim MUST reflect at least one of the high risk conditions described previously. " We all know what the high risks conditions are so ...... I believe that if a patient comes in with a history of a high risk polyp then that is a reason to do a high risk colonoscopy. If I bill G0105 and V12.72 then according to Medicare's guide I am following their guidelines. If I bill V76.51 and V12.72 then you would always bill G0121 and never have a reason to bill G0105. So why even have a G0105 code??????
 

btadlock1

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The "Guide to Medicare Preventative Services" does not say anything about using V76.51 as the primary dx for a high risk screening. On page 80 it states " However, when billing for the high risk beneficiary, the screening diagnosis code on the claim MUST reflect at least one of the high risk conditions described previously. " We all know what the high risks conditions are so ...... I believe that if a patient comes in with a history of a high risk polyp then that is a reason to do a high risk colonoscopy. If I bill G0105 and V12.72 then according to Medicare's guide I am following their guidelines. If I bill V76.51 and V12.72 then you would always bill G0121 and never have a reason to bill G0105. So why even have a G0105 code??????
Actually, the last reference I provided, comes directly from their guidelines - it's an MLN Matters Article, issued by CMS. The reason for the encounter is a screening colonoscopy; the risk should be clearly indicated - as a secondary diagnosis. I don't know why Medicare would have a separate code for high-risk patients, if it wasn't necessary to indicate that they were getting a screening, but they're not exactly famous for 'efficiency'. Please see below:

"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....

If you have any questions, please contact your Medicare carrier, FI, or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website."

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/SE0746.pdf

So, I suppose you'll have to ask CMS about it.
 

scorrado

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I guess I am just confused as to how you can get these colonoscopies paid by Medicare. G0121 is only supposed to be used every 10 years. So how is everyone getting paid when they bill G0121 with V76.51 and V12.72 every two - five years which is normally when the high risk patients get their colonoscopies repeated? I thought that was the purpose of the G0105 so it could be billed every 2 years. Any clarificiation would be appreciated. I want to be doing this right.

So this is how I bill a high risk pt with a history of high risk polyp (no polyps found)

G0105 - procedure
V12.72 - diagnosis - I don't use V76.51 at all.

If I am understanding Brandy correctly I should be billing:

G0121
V76.51
V12.72 - should never be primary - just information code.
 

btadlock1

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I guess I am just confused as to how you can get these colonoscopies paid by Medicare. G0121 is only supposed to be used every 10 years. So how is everyone getting paid when they bill G0121 with V76.51 and V12.72 every two - five years which is normally when the high risk patients get their colonoscopies repeated? I thought that was the purpose of the G0105 so it could be billed every 2 years. Any clarificiation would be appreciated. I want to be doing this right.

So this is how I bill a high risk pt with a history of high risk polyp (no polyps found)

G0105 - procedure
V12.72 - diagnosis - I don't use V76.51 at all.

If I am understanding Brandy correctly I should be billing:

G0121
V76.51
V12.72 - should never be primary - just information code.
No, you wouldn't use V12.72 on G0121; That's a high-risk indication. It's like this:

G0121
V76.51

G0105
V76.51
V12.72

Your MAC may accept G0105 with only V12.72 - they're allowed to tailor the rules to their jurisdiction. However, the national CMS guidelines say to bill it as listed above. You should check with your MAC to find out what they will and won't accept, and follow their recommendation.
 

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I feel I am missing something here. Suppose it is a Medicare patient with a history of colon polyps, but nowhere does the doctor indicate the colonoscopy is a screening. We have a form that disignates screening, so if it is not marked, I don't code it to a screening colonoscopy. From reading the posts, it sounds like I should assume it is a screening if the patient has a history of colon polyps. What's your opinion?
 

Lindseywingate1990

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that is my question. should i be assuming that a patient that comes in with no symtoms noted and the only indication is the patient has a history of colon polyps and is now here for evaluation. should i assume this is a screening and code V76.51??
 

coachlang3

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No you shouldn't assume anything. That whole saying "when you assume..." and all that.

That's when you should go back to the doctor to have them clarify. At the very least look at the last OV note and then go back to the doctor for clarification.
 

btadlock1

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I feel I am missing something here. Suppose it is a Medicare patient with a history of colon polyps, but nowhere does the doctor indicate the colonoscopy is a screening. We have a form that disignates screening, so if it is not marked, I don't code it to a screening colonoscopy. From reading the posts, it sounds like I should assume it is a screening if the patient has a history of colon polyps. What's your opinion?
I feel like a total jerk for this, but I think it might clear things up:
:eek:
"Screening/screen·ing/n.
1. The examination of a group of usually asymptomatic individuals to detect those with a high probability of having or developing a given disease.
2. The initial evaluation of an individual, intended to determine suitability for a particular treatment modality.


The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved."

http://medical-dictionary.thefreedictionary.com/screening

There are 3 main reasons for performing scope procedures, which all indications fall under: Screening, Diagnostic, and Therapeutic (eg, 'Surgical')
When there are signs/symptoms pointing to an active problem, the exploratory scope is considered 'diagnostic', because its intent is to make a definitive diagnosis on a presumed problem.
Therapeutic scopes are performed, in order to correct known problems.
'Screenings' are procedures performed in otherwise healthy patients, who have no current signs or symptoms that might lead the provider to believe that they will find something - they're preventive.

Having a risk factor for an illness, such as a personal or family history of having a problem, does not automatically render screenings, 'diagnostic'. Just because the patient had colon polyps in the past, doesn't necessarily mean that he will have them again - it just means that he has a higher probability of having them, than someone who hasn't had them.

But, going back to my original point - the primary diagnosis, (or the 'reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided' - which in this case, is an endoscopic examination of the colon), should indicate that the procedure is either diagnostic or therapeutic (as represented by 'problem' ICD-9 codes - all numeric), or, absent any current complaints, is a 'screening' procedure.

The risk factors demonstrate medical necessity for more frequent screenings (eg, personal or family history info, or other contributory risk factors, such as Crohn's disease), and are listed as additional diagnoses, according to ICD-9 guidelines. Does that make more sense?
 
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Scatlot

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Thank you Brandi and Coach Lang for your input. However, I still have a question regarding the statement "under no circumstances would you use V12.72 as a primary diagnosis." Since we can't assume, and it is not feasible to query to physician due to the high volume of procedures with many orders only having colonoscopy with a history of polyps marked. Thus when a patient comes in, and the colonoscopy is normal, I would code this:

45378 colonoscopy
v1272 history of colon polyps

I know as a coder that this should be a high risk screening, but I can only code from the information given. If I'm never supposed to use V12.72 as the principle diagnosis, and I can't query the physician, how else can it be coded? In this case it wouldn't matter if it was Medicare or a commercial insurance.
 

btadlock1

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Thank you Brandi and Coach Lang for your input. However, I still have a question regarding the statement "under no circumstances would you use V12.72 as a primary diagnosis." Since we can't assume, and it is not feasible to query to physician due to the high volume of procedures with many orders only having colonoscopy with a history of polyps marked. Thus when a patient comes in, and the colonoscopy is normal, I would code this:

45378 colonoscopy
v1272 history of colon polyps

I know as a coder that this should be a high risk screening, but I can only code from the information given. If I'm never supposed to use V12.72 as the principle diagnosis, and I can't query the physician, how else can it be coded? In this case it wouldn't matter if it was Medicare or a commercial insurance.

There's an exception for every rule - including "never make assumptions"...if you see documentation of a colonoscopy with a history of colon polyps, and no documentation of a current complaint (eg, signs, symptoms, etc.), you can (and should) assume that it's a screening colonoscopy. If there's nothing wrong with them, it's screening. The scenario you described could be coded one of 2 ways, depending on the payer...
For Medicare:
G0105 (Use a G-code when it's a screening, and no abnormalities are found)
V76.51
V12.72

For Commercial payers who don't accept G-codes:
45378-33
V76.51
V12.72


Before the colonoscopy begins, they either have something wrong with them (that the provider knows of), or they don't. Your primary Dx has to indicate whether the colonoscopy is happening because the patient has been having problems (diagnostic or surgical), or if it's just to check, to make sure no problems have developed (screening). It will always be one or the other - you'll either code a current problem as the primary diagnosis, or a V-code. If you're using a V-code, it's a screening, and you should use the appropriate V-code to describe a screening colonoscopy, which is V76.51.

"History of colon polyps" doesn't tell you whether the indication for the colonoscopy is diagnostic, surgical, or a screening - it only tells you that they had colon polyps in the past. It is a risk factor, not the reason for the encounter. It justifies the frequency in which the patient is having the procedure done, but not the purpose of the colonoscopy. I know it's a little confusing, but I really can't think of any other way to explain it.
 

coachlang3

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There's an exception for every rule - including "never make assumptions"...if you see documentation of a colonoscopy with a history of colon polyps, and no documentation of a current complaint (eg, signs, symptoms, etc.), you can (and should) assume that it's a screening colonoscopy. If there's nothing wrong with them, it's screening. The scenario you described could be coded one of 2 ways, depending on the payer...
For Medicare:
G0105 (Use a G-code when it's a screening, and no abnormalities are found)
V76.51
V12.72

For Commercial payers who don't accept G-codes:
45378-33
V76.51
V12.72


Before the colonoscopy begins, they either have something wrong with them (that the provider knows of), or they don't. Your primary Dx has to indicate whether the colonoscopy is happening because the patient has been having problems (diagnostic or surgical), or if it's just to check, to make sure no problems have developed (screening). It will always be one or the other - you'll either code a current problem as the primary diagnosis, or a V-code. If you're using a V-code, it's a screening, and you should use the appropriate V-code to describe a screening colonoscopy, which is V76.51.

"History of colon polyps" doesn't tell you whether the indication for the colonoscopy is diagnostic, surgical, or a screening - it only tells you that they had colon polyps in the past. It is a risk factor, not the reason for the encounter. It justifies the frequency in which the patient is having the procedure done, but not the purpose of the colonoscopy. I know it's a little confusing, but I really can't think of any other way to explain it.
I agree totally with Brandi on all her points. I said never make the assumption but I should have added "until you cover all your areas". Meaning if you can't check with the doctor, go over the previous documentation for the most immediate office visits.
 

Kisalyn

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I am with you Scatlot. That is the way I have been sending through colons. This is an interesting discussion.
 

coachlang3

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Then like Brandi said-

Medicare:
G0105-V76.51, V12.72 (unless your MCR carrier allows just the use of the V12.72 since the screening code is inherent in the HCPCS code)

Commercial carriers:
45378-V76.51, V12.72 (every commercial payor I've come across wants it/accepts it that way for some reason)
 
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