Wiki Need help...Colonoscopies


Indianapolis, IN
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We are having a disagreement about how a certain colonoscopy should be billed. The patient had a screening colonoscopy in Feb. 2008 and it was billed as 45384 with Dx 211.3 and V16.0. Then the patient was seen again March 2011 and it was billed as 45378 with
V12.72. The payer is Anthem. Of course the insurance applied it the patient's deductible and the patient called. After reading Anthem's policy. I felt it was billed wrong and that the patient qualified as a "high risk" patient and I feel it should be billed as G0105 with V12.7. I thought that a diagnostic procedure should be coded with a diagnostic diagnosis. Someone please tell me what the correct billing should be. If I am wrong I need to know and I need to understand why. I have added Anthem's policy.

Okie dokie, here we go, lol.

You can still use a 45378 CPT code but you would then have to use the dx code of V76.51 followed by the V12.72.

Or you could use the G0105 with the V12.72 if your contract with BCBS allows it.
We are contracted with BCBS and I recoded it as G0105 with V12.72 and it was paid in full but the MA at the doctor's office is disagreeing with me tell me I am wrong and she is right and they will not even read the Anthem policy. They want me to change it back to 45378 due to the patient now wants the facility to change their codes to match mine and they won't due to what the MA is saying. If I lose this battle I will attempt to bill it as 45378 with V76.51 with V12.72 as you suggested.

I really doubt a MA in the doctors office is qualified to say how a procedure should be coded.
It depends on what the doctors note says also. Did the patient come back for surviellance due to family history? (V16.0) That would be a high risk screening.
Trust me I agree.......The pt came back for history of polyps V12.72. They call it a rescope and state that a screening can only be billed once no matter a regular screening or high risk screening. Which does not make since to me at nor is that what it states in the policy.
A couple ways

I've billed the exact situation many times. If the insurance company allows I'll bill G0105, V12.72, V16.0. On the other hand if the insurance company doesn't allow the HCPC code, I'll bill 45378-33 or PT, V76.51 V12.72 V16.0

Good luck! I'd call the facilities billing department personally and request they adjust the coding and leave the MA out of it all together.

I agree. The screening colonoscopy in 2008 should have been coded as follows:
453-- diag: V76.51,V16.0 (if fam Hx of Malig Neo), 211.3.

The most recent colonoscopy: 45378--V12.72, V16.0. Indicate in report last colon perform in 2008. High Risk Patient.