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Pathology & screening dx

karacombs

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Austin, Texas
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I have a question about pathology coding. If a patient comes in for a true screening colonoscopy, would it be appropriate to code the V76.51 as the primary dx on the pathology (technical component) claim with the 211.3 as the secondary dx? This is how we send out our procedure claims so it would stand to reason it would be OK to do the same for the path claim.
 

DEDGE CGIC

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Payer guidelines

You will likely find a lot of back and forth on this matter. There are a couple posts from 2010 on this matter which do not definitely answer this question. There are few published guidelines in reference to the proper coding guidelines for a screening colonoscopy turned diagnostic, but none that I have found so far refer directly to pathology. One of the 2010 posts contains several references to coding guidelines and payer guidelines. As coders we sometimes end up with tunnel vision and don't see the full picture. We also have to view each situation as a biller as well. By opening up and understanding all payer guidelines individually you will find more accurate reimbursement by the individual payer guideline which may fall outside of "coding" or "Medicare" guidelines. If we code and bill every payer the exactly the same we would reduce our reimbursement and with high probability increase the patient liabilities which of course increases angry calls from the patients unnecessarily. If the individual commercial payer is stating that per their policy and guidelines that for the service to be correctly reimbursed it needs to be billed routine primary it is more than proper to follow those individual guidelines. I have had the same quandary here since we started billing pathology internally. For my appropriate commercial payers I bill: 88305 V76.51, 211.3.
Now you will find Medicare will require the coding to be 88305 211.3 due to the claim edit within their system will be requiring a G code to match the screening code. I have experimented with the PT modifier on this and have not found success. The main thing to remember is that even if there is additional liability by Medicare most patients have supplemental coverage and don't care. And those without secondary coverage don't tend to have a large enough liability to find concern.
You may also want to review your documentation guidelines on how the pathology group is documenting the histology. Ours have the presenting "screening colonoscopy" as well as the Specimen identified. This way if a payer (which I have yet to run into) does dispute the coding you have both the op report as well as the histology report to help support your coding decision. Again despite wishing there was one constant and concise answer that worked across the board we probably wouldn't have a job. Hope this helps.
 
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282
Location
Pensacola, Florida
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I agree with the previous post. We submit our commercial pathology charges as v76.51/211.x, etc. We found that the patients' screening benefit applied to the pathology charges. We also list the v code first for all our Replacement plans. We do not use the v code for Medicare or Medicaid.
 

mitchellde

True Blue
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13,538
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Columbia, MO
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The ICD-9 Cm coding guidelines that applies to ALL payers and ALL providers states to use the screening V code first listed for screening procedures and findings must be listed as secondary dx codes. We cannot vary how we code the diagnosis based on who the payer is, who the patient is, or what type of benefits they have. We always code based on the established guidelines which are mandated by HIPAA.
 

DEDGE CGIC

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If you follow the same guidelines for all payers you would end up billing G0121 and G0105 to match your V codes and would be reducing your financial reimbursement commonly between $250.00 to $500.00 per procedure. As well by not following the payer's established guidelines you can run into denials and rejections. So again coding every payer exactly the same doesn't make established financial sense. I know getting away from "coding guidelines" is contriversial, but when each payer publishes and specify individual guidelines why wouldn't you follow them. I wish there was an absolue accross the board guideline on coding, but there isn't. As far as HIPPA requiring a policy of consistant coding by all payers I'd be very interested to find this documentation. Given the vast volumes of information envolved are you aware of where i can locate this information?
 

DEDGE CGIC

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responce

If you follow the same guidelines for all payers you would end up billing G0121 and G0105 to match your V codes and would be reducing your financial reimbursement commonly between $250.00 to $500.00 per procedure. As well by not following the payer's established guidelines you can run into denials and rejections. So again coding every payer exactly the same doesn't make established financial sense. I know getting away from "coding guidelines" is contriversial, but when each payer publishes and specify individual guidelines why wouldn't you follow them. I wish there was an absolue accross the board guideline on coding, but there isn't. As far as HIPPA requiring a policy of consistant coding by all payers I'd be very interested to find this documentation. Given the vast volumes of information envolved are you aware of where I can locate this information?
 

mitchellde

True Blue
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Columbia, MO
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The HCPC vs CPT code is very different from the diagnosis code. The diagnosis code guidelines are mandated by HIPAA these are what I am referring to you cannot not follow these for the diagnosis code assignment ans sequencing. The diagnosis code is the patient's and we must follow the same guidelines for all HIPAA providers and payers. That means the screening V codes are first listed always when the reason for the test is screening, the findings are secondary.
As far as the CPT codes are concerned we use the HCPC codes for Mcare, some of these are designated as carrier discretion and we may use those for other carriers as requested, otherwise we use the CPT codes.
As far as the directive for the ICD-9 codes this comes from page 1 of the official guidelines for ICD-9 CM:

These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).
 
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DEDGE CGIC

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Medicare's system for claim edits won't allow pathology to be coded as commercial carriers request it to be coded. That's why I have to make the differential in this coding process. Just like if I have a payer that doesn't have any routine benefits in the patient's plan the coding edit would indicate to omit routine codes and submit with medical indicators or findings. I still cannot find any specified guideline that states we cannot code payer specific, If the payer is requesting said differentials. If anyone has non-interpretive concise material I'd be very interested in viewing it.
 

mitchellde

True Blue
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13,538
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Columbia, MO
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but you cannot change codes just because of a coverage issue! The paragraph i quoted above came from the coding guidelines first page. These are probable in the front of your coding book. You code per the documentation, and if the documentation supports this was a screening with findings then that is how it MUST be coded regardless of the patient's benefits and coverages.
 

DEDGE CGIC

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Then we'd be completely dependant on our physicians to document every service correctly and without editing the physicians coding per payer guidelines we'd never get paid. Just like several cases where the physician documents screening inappropriately on a patient who is not age appropriate. I wouldn't code it with the screening code because it is not appropriate for individual situations. I wish all of my physicians were coders, but then I'd be obsolete.
 

mitchellde

True Blue
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13,538
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Columbia, MO
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You can only code from the documentation! A provider may order a screening anytime he feels it is appropriate. It is not up to the coder to determine if the documentation is correct, only if the codes match the documentation. You are allowed to change the providers assigned codes but only if they have selected incorrect codes based on what they documented. There are many times a screening is correct even if the age criteria has not been met. You are not allowed make the determination that the documentation is inappropriate or that the treatment or tests ordered are inappropriate. It is about the patient as documented by the provider always. It is not about what dx code the payer considers payable or covered. To code anything other than what is documented is fraud. I apologize but there is no nice word for it. I am very concerned by the way you have stated the manner in which you select codes.
 
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coderforlife

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Salem, OR
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screening codes

hello true blue,
I agree with you. if the physician indicates the reason for a test is a screening for lets say cystic fibrosis, then it should be coded that way. But I have been directed by my coding manager not to use the screening codes, but use a code for signs or symptoms otherwise we will not get paid. I believe this happens so often not just at my place of work. Especially if it is a Medicare patient. I have been frustrated with this situation for some time and it was nice to see someone else in this forum that looks at this issue the same way as I do.

Coderforlife :)

p.s. time to clear your mailbox. ;)
 
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