Pathology after screening colonoscopy

bbeatty

Networker
Messages
48
Best answers
0
When a colonoscopy begins as screening but a polyp is taken how is the pathology for the polyp billed? We typically just bill 88305 with the dx of the polyp but Highmark is telling patients that we should bill the pathology as screening. Does anyone have any experience with this??
 

Pam Brooks

True Blue
Local Chapter Officer
NAB Member
Messages
2,093
Location
Dover Seacoast New Hampshire
Best answers
0
A pathologist is a physician, and therefore their final diagnosis and findings should be reported as the first-listed diagnosis. Although the intent of the colonoscopy was a screening, that code should be appended to the screening colonoscopy, not the pathologists' claim, since his tissue analysis shows a confirmation of a polyp. See AHA Coding Clinic 1Q2017.

The insurance company is telling the patient this because 1.) they aren't coders, and 2). their insured is upset because they are going to have deductible/co-insurance responsibility for the pathologist's bill, instead of a screening visit, which has no patient responsiblity. The payer is telling the patient that it was 'coded wrong', so that the payer won't have to take the heat for the patient being upset.

If I had a dollar for everyone of these scenarios that has crossed my desk since the ACA was implemented, I would be on a beach in Tahiti right now, sipping margaritas. It's a pain that the payers throw coders under the bus, when they don't even understand the rules.

We should not code for payment/coverage reasons.
 

mitchellde

True Blue
Messages
13,420
Location
Columbia, MO
Best answers
1
working in Pathology, most of the time I had no idea that the polyp came from a screening procedure. All my documentation was about the polyp. The pathologist is only reporting the results of what they examined, they are not coding for the procedure. So the procedure was screening and from the view of the provider that performed the procedure the screening is the reason and the first listed code with the polyp as secondary since it is an incidental finding. I agree with Pam the payer needs to quit trying to blame everything on the coder that is doing their best to follow all the convoluted and ever changing rules of the game.
 

thomas7331

True Blue
Messages
2,257
Best answers
5
When a colonoscopy begins as screening but a polyp is taken how is the pathology for the polyp billed? We typically just bill 88305 with the dx of the polyp but Highmark is telling patients that we should bill the pathology as screening. Does anyone have any experience with this??
I agree with Pam and Debra, and I've seen this scenario often too. My advice has always been that any time a payer representative tells you how you 'should' bill, you're first response to them should be to ask them where you can find this in writing - if they are saying this, they should be able to back this up by showing you a policy or document that supports it. In some cases, like Pam says, they are just making an excuse to avoid blame, but in others, the payers sometimes do actually have a policy in writing as to how they expect a claim to be billed in order for benefits to be applied correctly. If you do have such written support, you can bill according to that payer's guidelines, but otherwise you can't just accept their word for it and have no choice but to stick with the guidelines. And in some of these cases, you or the patient may just have to appeal these in writing with notes to demonstrate that it was in fact a screening in order to get the claims paid correctly.
 

marybrady1

Contributor
Messages
10
Location
Harrisburg, PA
Best answers
0
I will apply ICD 10 Z12.11 (encounter for screening colonoscopy) as a secondary or last diagnosis code to a colon polyp biopsy ONLY if the clinical information on the pathology report states the encounter is a screening colonoscopy.
 

Lcubed

Contributor
Messages
12
Best answers
0
Pathology for colonoscopy

This always ends up as a question with us as well in Pathology coding. All of the recommendations, rules etc. are based on the GI procedure code but nothing is mentioned about the Pathology procedure code (88305). If we even get the screening code (rare) we usually don't enter any code beyond the pathologist diagnosis (not even as a secondary). And then we get the patient calls and complaints. There is a reference here to a coding clinic which I do not have access to (I only see the professional billing). I think it would be helpful to get this pathology diagnosis information out "there" - Padget does address it in the Pathology Service Coding Manual.

Thanks for the information!
 

bbeatty

Networker
Messages
48
Best answers
0
I came across a letter that was sent to my providers from UPMC that addresses this issue. In the letter, UPMC Vice President of Network relations, contracting and reimbursements tells us that when a patient's procedure begins as screening but turns diagnostic then "all same day services such as anesthesia, pathology, and facility fees should also be appended with modifier 33". Since we have our own pathology lab it is easy enough for us to find this information when billing. I just thought that I would share with all of you.
 
Top