Wiki Medicare pt screening colonoscopy scenerio

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busydawnis

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A Medicare patient presents for a screening colonoscopy and lower abdominal tenderness..full colon is done...findings...diverticulosis and hemorrhoids.

Coded as follows....
G0121 with v76.12 and 562.10

My supervisor is saying since the doctor found diverticulosis, then the colonoscopy should have been coded as a diagnostic with 45378. She states that if the screening does not come back normal then it is not a screening anymore and the diagnostic code needs to be used with the findings..

Please advise me on how other coders would codes this....:confused:
 
The coding guidelines are very clear on this issue, if the patient presents for a screening then the screening dx remains primary regardless of the findings, the findings will be secondary. If the patient presents symptomatic then the exam is not screening from the beginning and is coded as a diagnostic and the symptom may be replaced with the definitive dx
 
Screening Colon

January 2004 page 4
Coding Communication:Colonoscopy Coding Made Simple from CPT Assistant

The public awareness of colorectal cancer screening and surveillance has increased dramatically over the past several years. Colonoscopy is the most effective diagnostic procedure for colon polyps and early colorectal cancer. While this procedure is performed more than 2 million times each year, questions about colonoscopy coding for biopsy and removal of colorectal polyps continue. Proper determination is achieved by carefully considering the code descriptors and similarities that exist as well as the intended use of the codes and the potential problems.

Codes in Question

45378Colonoscopy, flexible, proximal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression
45380with biopsy, single or multiple
45381with directed submucosal injection(s), any substance
45383with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45384with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
Medicare uses unique procedural codes to identify claims for services when colonoscopy is performed strictly for colorectal neoplasia screening in patients with average risk (G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) and high risk (G0105, Colorectal cancer screening; colonoscopy on individual at high risk) for colon cancer. In these cases, the unique Medicare code is reported instead of the standard CPT colonoscopy code (45378) when there is no need for a therapeutic procedure. Therapeutic procedures include simple biopsies, snare polypectomy, etc. If a therapeutic procedure is performed, then the appropriate CPT code(s) are reported with the ICD-9-CM diagnosis code that reflects the finding that required the therapeutic procedure. The diagnosis code reflecting the indication should be listed secondarily. If there is no need for a therapeutic procedure, the Medicare G-code is listed with an ICD-9-CM code reflecting the indication. The ICD-9-CM code for screening colonoscopy examinations in average risk patients is V76.51. There are several acceptable ICD-9-CM codes for screening colonoscopy in high risk patients. Incidental findings (eg, diverticulosis, hemorrhoids) not requiring therapeutic procedures can be identified as an additional ICD-9-CM code(s) after the ICD-9-CM code reflecting the indication for the procedure.

Hope this helps!!!:)
 
OK, MCR screening you would code as follows:

G0105/G0121 with the dx of V76.51 or V16.0 or V12.72 (or whichever)

if there are findings during the proc, we have found that MCR accepts the following:

DX V76.51
45378/45380 (or whatever) and then the dx 562.10 (diverticulosis)

the V76.51 code would be the prime dx and the finding would be secondary. With our software we put "DX" in place of the proc code and the V code on the first line and the proc (45378) and the finding dx (562.10) on the second line.

however, you mention the patient presented with lower abdominal pain
(789.00, depends if you know LLQ or RLQ).

In this case there is no screening as the patient has symptoms.
 
Last edited:
Speaking of Medicare and screenings

If a patient is Medicare and comes in for a followup to a polyp 3 years ago and nothing is found this time, do you use the G code or the 45380.

Since doctor is calling it a followup, does that take out the option of using the G code, since it is not a screening? Since the patient is now considered high risk because she had a polyp in the past, do you still use the G code for a followup to a polyp? If the guideline states that a high risk patient is one who has hx of polyps when they are now all followups?

Which came first, the chicken or the egg?

My confusion lies with the patient now considered to be high risk since she did have a polyp in the past, and this exam nothing found, so use G code, but this is not a screening, it is a followup. What makes it a screening where you would use the G code if nothing is found and what determines not using the G code?
 
Is the patient actively having problems or did they just do the follow up cscope because they are at high risk due to history of polyps?

I would consider this a screening unless there is something else going on besides history of whatever.

Just because they found polyps once doesn't mean they will find them again, if all were removed and the patient is having no problems it really is just a screening due to high risk history.

Just my opinion,

Laura, CPC, CEMC
 
Thank you, Laura, so

Right, no symptoms, just a followup for a polyp. Because Medicare says anyone with a history of an adenomatous polyp and also a family history of colon cancer (also present) is a high risk patient. A high risk patient can have screenings every 2 years. If the colonoscopy finds nothing, then you need to use the G code. So even though the doctor is calling this a followup to a polyp, what it is, in Medicare's eyes is a high risk screening. Medicare says I have to use the G code in this case. I didn't know if I could use that with a V67.09 code or I needed to change it to V76.51 to match the G screening code. I am just reasoning this out, other opinions welcome! Thank you. These have me going in circles.
 
Jamshidi,

Is the doctor doing an actual procedure? If they did, then it would be a G code (G0105-high risk screen) with a dx (V12.72 Personal history of colon polyps).

If this is just a f/u office visit, you can still use the V12.72.
 
It doesn't say screening, but does it indicate a problem? History of polyps is not a current issue. If there is no current problem you can't really bill it as anything but a screening would be my take on that.

Laura, CPC, CEMC
 
If the pre-operative indications/Diagnoses includes lower abdominal tenderness this would not be a screening colonoscopy--it would be diagnostic. I would be looking at 789.6x codes for abdominal tenderness and 562.10 as the findings. I'd check your LCD and determine if 789.6x supports medical necessity.
 
Well, still not absolutely clear but

V12.72 and V16.0 support G0105. Since the doctor calls it a followup, that is what I should code it as with those two codes. Since nothing was found, I will use the G0105 with them. I don't feel I can call it a screening if it is not documented as such. (The interpretation of the word screening is all over the place also). If Medicare wants us to follow their rules it really should be spelled out clearly; otherwise, they will get a mishmosh of codes entered by conscientious coders trying to interpret their rules, which is not fair to the patient if some are denied! Thanks to all who tried to answer my question.
 
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