Wiki Polyp w/screening colonoscopy

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cindyseyer

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We have been using dx 211.3 for adenomatous polyps when found on screening colonoscopy. Recently, we have had several patients complain that if we had coded it V76.51 first and 211.3 second, their insurance would cover the charge under their preventative benefits. Although the procedure may have begun as a screening procedure, I believe the pathology should be medical. Can anyone direct me to any literature about this or tell me how they handle this situation? Thank you for your help.
 
Yes the screening is always first when the purpose of the test is screening regardless of the findings. The coding guidelines state this as well.
 
I'm sorry but the correct DX is 211.3 not the screening code. “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening.” (ICD-9-CM 2008, pg. 71 or 74):eek:
 
I agree tomtom, however the original post stated this was a screening colonoscopy wich is not diagnostic. The guidelines also specify that when the pupose is a screening exam the first listed code remains screening regardless of the findings or any subsequent procedure performed. So if it were screenng there is nothing suspected and there are no symptoms. That is essentially the difference between screening and diagnostic.
 
Guidance states that the attending physician should report the V-code as the primary diagnosis, that direction does not carry through to the pathologist. The pathologist received the polyp for diagnostic testing. Which I would then refer you to my last post regarding testing of a person to rule out or confirm a suspected diagnosis.
 
there are no separate diagnosis guidelines for the pathologist, it was still screening. The specimen was a result of a screening not a diagnostic.
 
Per Medicare - the principal diagnosis to report on pathology services (TC or PC) is the pathologist's diagnosis if one can be rendered. The pathologist made a definitive pathologic diagnosis of adenomatous polyps.
 
Thank you for your input; I can see the views from both aspects. I have tried to find literature on this subject with no success. Can you direct me where I can find it--NCD, etc?
 
Found It! MLN Matters Number: MM2874

This is some text from MLN MM2874: "Once every 48 months, one Flexible Sigmoidoscopy examination is covered for beneficiaries age 50 and over. If, during the course of a screening Flexible Sigmoidoscopy, a lesion or growth is detected which results in a biopsy or removal of a growth, the appropriate diagnostic procedure (such as Flexible Sigmoidoscopy with biopsy or removal) should be billed rather than just a Flexible Sigmoidoscopy examination. "

This also means that the referring dr should have not given you a screening V-Code and should have given you the appropriate signs/symptoms DX. For which the biopsy or removal was done for.

In general, all true AP specimens are derived from diagnostic procedures and thats all I have to say on the matter.
 
I totally under stand your position and it is all true for diagnostic studies.... HOWEVER if this is a screening then there are no signs or symptoms to report. Again this is the difference between screening and diagnositc. They are two very different issues and should not be confused. When a patient presents for screening they do so based on having met some prescribed criteria such as age, they have no symptoms and no reason to believe there are any issues. The same goes from the provider aspect , they exam a healthy patient with no complaints and order a screening, IF there are findings, they are incidental to what was expected ( a clean colon) and incidental findings are secondary. To report this any other way canbe/is damaging to the patient, benefits can be denied, premiums can go up. I am not saying that this affects how we code, rather we must always be correct with our coding because of how that affects the patient.
 
Always if it is a Screening Colon you Code V76.51 followed by the findings. Read your CPT Assistance.

Kimberly CPC
 
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If you are looking for documentation on the subject you can go to CMS website to the MLNMatters article:

http://www.cms.gov/MLNMattersArticles/downloads/se0746.pdf

There it describes it as the following:

``if during the course of such screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening colonoscopy but shall be made for the procedure classified as a colonoscopy with such biopsy or removal.'' Based on this statutory language, in such instances the test or procedure is no longer classified as a ``screening test.'' Thus, the deductible would not be waived in such situations."

Where the patient would have no deductible for a screening colonoscopy (V76.51), because something was sent to the pathologist (211.3 or 211.4), it is no longer screening and the deductible would be applied. Hope this helps.
 
They are talking about the procedure code not the diagnosis code. The diagnosis does not change from screening. The procedure code will be the colonoscopy with biopsy as it cannot be coded with the G code for the screening colonoscopy. Remeber the dx belongs to the patient and the coding guidelines specify " the diagnosis remains screening first listed regarless of the findings or a subsequent procedure performed."
 
Keep reading the article -

it tells you to use V76.51 as the first code and 211.3 as the second code, but on the claim, link the pointer to the second dx only- which is 211.3.
 
Yes that is what I am saying, but you do not drop the screening dx code and you do not add any signs or symptoms, the procedure was for screening and the screening dx remains the first list dx code. The fact that the 211.3 is the number 2 dx code and carries that designation says this. If Medicare wants to not waive the deductible then so be it but other payers may be different, as long as th coding is correct we must let the payment fall where it naturally will fall.
 
Your ICD-9 coding maybe correct for the dr that performed the colonoscopy. But question for this post was for the ICD-9 coding for the pathologist. Per both the MLN Matters quoted here the procedure became diagnostic when the rendering dr decided to take a specimen. Per Medicare any diagnostic test that the pathologist performs and renders a definitive DX for; that DX should be used as the primary ICD-9 for said test. Which means the pathologist should report 211.3 for the specimen.
 
I do not do pathology billing but what you are saying tomtom makes sense to me. Pathology is dealing with a polyp, therefore their coding has to do with the specimen. The specimen is not "screening" - the specimen is a polyp. Just my take on the situation.
 
I've edited my long initial reply to this:

Screening may be the primary code for the colonoscopy but it was the discovery of the polyp/possible neoplasm that led the specimen to be sent to Pathology. The primary code of for the specimen is not screening because abnormal tissue has been identified. It would be a screening if there were no detectable abnormalities.

I suspect few patient's get referred to specialists for screenings without any symptoms. The same is true of surgical pathology specimens. Removing seemingly healthy tissue would not be medical necessary. Removing some cells, as in a pap smear, is different from a surgical procedure and that is not a surgical pathology specimen. It is also interpreted rather than diagnosed and that is why it arrives with a screening code attached and that primary code does not change.

Surgical pathologists are referred specimens that have clinical indications other than screening.
 
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a little late to chime in but I agree with tomtom and the others who have stated it this way.
The ICD-9 guide declares the “testing of a person to rule out or confirm a suspected diagnosis [for example, cancerous colon polyp] because the patient has some sign or symptom [for example, polyp] is a diagnostic examination, not a screening.” {ICD-9-CM Official Guidelines for Coding and Reporting, Oct. 1, 2009, pg. 73} Therefore, the pathologist is to report the ICD-9 code that corresponds to his/her examination findings as the primary diagnosis on the claim, even though the tissue was obtained during a screening procedure; however, should the pathologic exam fail to yield a definitive diagnosis, the pathologist should report the sign or symptom (e.g., 569.89 or 569.9 or polyp, etc) as the primary diagnosis on his/her claim and not the V-Code for screening.
 
bgilmore said:
a little late to chime in but I agree with tomtom and the others who have stated it this way.
The ICD-9 guide declares the “testing of a person to rule out or confirm a suspected diagnosis [for example, cancerous colon polyp] because the patient has some sign or symptom [for example, polyp] is a diagnostic examination, not a screening.” {ICD-9-CM Official Guidelines for Coding and Reporting, Oct. 1, 2009, pg. 73} Therefore, the pathologist is to report the ICD-9 code that corresponds to his/her examination findings as the primary diagnosis on the claim, even though the tissue was obtained during a screening procedure; however, should the pathologic exam fail to yield a definitive diagnosis, the pathologist should report the sign or symptom (e.g., 569.89 or 569.9 or polyp, etc) as the primary diagnosis on his/her claim and not the V-Code for screening.
Click to expand...
The problem I am having is that if it is ordered as a screening, then there is no complaint or signs or symptoms so that guideline does not apply, the guideline for screening applies that states if the purpose of the procedure is screening the screening remains the first listed dx regardless of the findings or any subsequent procedure. You cannot change horses mid stream, if it was screening as the intent then it is screening all the way through. The finding of the polyp is incidental and must be reported secondary. The patient had no complaint and no symptoms and we cannot communicate that the did, what they have is an incidental finding that needs further study and the pathologist needs to reflect this as well so that any benefits the patient has stay intact. It is not fraud either, since there was no reason to suspect that anything would be found.
I understand what everyone is saying but I am presenting it in a different light, the guideline you are referencing states:“testing of a person to rule out or confirm a suspected diagnosis [for example, cancerous colon polyp] because the patient has some sign or symptom [for example, polyp] is a diagnostic examination,...."
Which is true for a diagnostic study, but in the scenario of a screening there is no reason to suspect anything and there are no signs or symptoms..
 
The confirmed polyp is the sign and symptom. This is not a "screening polyp." It is abnormal tissue submitted for pathologic exam and diagnosis. This 88305 is Polyp, colorectal, not Colon, biopsy. The clinical dx on the referral form should be "polyp" because that is what it is.

The colonoscopy by the clinician should be coded as you have described per ICD-9-CM.
 
I see both views on this. The problem I have with reporting only the 211.3 is that the insurance companies do not make patients aware that if there is a polyp found, their service is no longer covered at 100%. Most policies state that a screening colonoscopy is covered at 100% for preventative purposes but never mention if something is found, you are responsible. In fact, many insurances tell the patient if the claim is resubmitted with a screening code as primary, they will reprocess under the screening guidelines. It seems unfortunate that if a screening pap smear shows a positive result, the patient is still entitled to screening benefit, yet a patient who has an incidental finding of a polyp is now responsible for a deductible and a coinsurance. I think it is time for the insurance companies to clarify their position on this.
 
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http://www.cms.gov/ColorectalCancerScreening/

I have also read a MLN Matters article specifically stating how to bill a screening colonoscopy when polyps are found and removed. It states that, because you can't use the G0105 or G0121 when a polyp is removed, they (Medicare) still want the V76.51 on the claim and "pointer" 1 BUT to attach the 211.3 to the procedure (45380/45385 etc). Their reasoning was due to deductibles and coinsurance that applied to the screening colonscopy, but now that this is all going to change and Medicare is paying 100% on all eligible screening tests, I am not sure that this guideline with be invalid. I am looking for this article, I will post a link once I find it.
 
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Jan 1, 2011, CMS is waiving the deductible for colorectal screenings that become diagnostic. See the "Coding Edge", December 2010 article, pg 8.

Go to cms.gov/apps/media/fact_sheets.asp
click "November 02, 2010" link
click "Final 2011 Policy, pay changes In Medicare Physician Fee Schedule"

"Elimination Of Deductible And Coinsurance For Most Preventive Services: Effective Jan. 1, 2011, the Affordable Care Act waives the Part B deductible and the 20 percent coinsurance that would otherwise apply to most preventive services. ... The Affordable Care Act also waives the Part B deductible for tests that begin as colorectal cancer screening tests but, based on findings during the test, become diagnostic or therapeutic services."
 
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