Question Positive Cologuard 1.5 yrs ago with no follow-up, Colonoscopy today

jfolz

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Hi all,
I code for an Outpatient Surgery facility and have a question regarding a Positive Cologuard patient. The patient in question has BCBS insurance and the physician has noted that "This visit is a screening due to no current active symptoms and a previous positive Cologuard that was never followed up on".
I know that a positive Cologuard indicates that the "Screening" isn't really a screening anymore, it becomes diagnostic due to the Cologuard using up that screening benefit and becoming an active sign and symptom of it's own...but in a case like this one, how long does that "positive" disqualify the patient from a screening? Is this affected by the physician's call- in this case the physician is seemingly disregarding it and calling for a new screening since it happened and was not followed up by a more definitive test? I think insurance will disagree, as they paid already for this patient to have a screening test performed. We have a lot of trouble with this physician's office because they indiscriminately send "Screening" on every case, regardless of existing symptoms.
The positive Cologuard in question was from 16 months ago.
It hasn't been 2 years yet since the initial positive Cologuard and to my knowledge, even the Medicare highest risk screening category isn't less than 2 years... I have searched online to no avail. Does anyone have any information on this scenario? The office is billing this as a screening z12.11 with a secondary dx of R19.5 according to their paperwork but I don't think this is correct and I'm unsure how to back myself up on this stance if questioned.
 

llhogeland

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**You are correct, this would NOT be a screening! Per the policy it would not be a screening for 10 years. Unless this colonoscopy put the patient into the high risk category then it would drop to 24 months

From BCBSKS

POLICY A. DNA analysis of stool samples using Cologuard™ may be considered medically necessary as a screening technique for colorectal cancer in average risk, asymptomatic individuals between the ages of 50 and 75 years when no other colorectal cancer screening has been performed during the recommended screening interval:

1. Guaiac-based fecal occult blood test in the past year, or
2. Fecal immunochemical test in the past year, or
3. Multitargeted stool DNA test in the past 3 years, or
4. Colonoscopy in the past 10 years, or
5. CT colonography in the past 5 years, or
6. Flexible sigmoidoscopy in the past 5 years.

B. In individuals who are considered candidates for Cologuard™ screening, repeat testing at intervals of every 3 years may be considered medically necessary.

C. DNA analysis of stool samples is considered experimental / investigational when the criteria above are not met and for all other indications including post colorectal cancer diagnosis surveillance.

D. All other screening stool DNA tests are considered experimental / investigational.

Policy Guidelines
1. Average risk of developing colorectal cancer include those individuals who have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn's disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.
2. Asymptomatic individuals include those who have no signs or symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test.
3. Individuals with an estimated life expectancy of less than 10 years should not be screened for colorectal cancer.
 

jfolz

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**You are correct, this would NOT be a screening! Per the policy it would not be a screening for 10 years. Unless this colonoscopy put the patient into the high risk category then it would drop to 24 months

From BCBSKS

POLICY A. DNA analysis of stool samples using Cologuard™ may be considered medically necessary as a screening technique for colorectal cancer in average risk, asymptomatic individuals between the ages of 50 and 75 years when no other colorectal cancer screening has been performed during the recommended screening interval:

1. Guaiac-based fecal occult blood test in the past year, or
2. Fecal immunochemical test in the past year, or
3. Multitargeted stool DNA test in the past 3 years, or
4. Colonoscopy in the past 10 years, or
5. CT colonography in the past 5 years, or
6. Flexible sigmoidoscopy in the past 5 years.

B. In individuals who are considered candidates for Cologuard™ screening, repeat testing at intervals of every 3 years may be considered medically necessary.

C. DNA analysis of stool samples is considered experimental / investigational when the criteria above are not met and for all other indications including post colorectal cancer diagnosis surveillance.

D. All other screening stool DNA tests are considered experimental / investigational.

Policy Guidelines
1. Average risk of developing colorectal cancer include those individuals who have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn's disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.
2. Asymptomatic individuals include those who have no signs or symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test.
3. Individuals with an estimated life expectancy of less than 10 years should not be screened for colorectal cancer.
I can't thank you enough for sharing this knowledge! I have had a few battles with this office recently and I just wish they would educate their physicians and office staff :(
 

MC1260

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@jfolz I have the exact same problem they put screening on every single case and I don't feel comfortable coding as such when it's obvious that it is diagnostic. I was told to code it the same way as z12.11 primary and the R19.5 as secondary. So how do we decipher what to code is it our responsibility to code as we see it or code according to the documented op report?
 

csperoni

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@jfolz I have the exact same problem they put screening on every single case and I don't feel comfortable coding as such when it's obvious that it is diagnostic. I was told to code it the same way as z12.11 primary and the R19.5 as secondary. So how do we decipher what to code is it our responsibility to code as we see it or code according to the documented op report?
My reply is not specific to colonoscopy screening vs diagnostic, but rather about coding in general.
1) The physician may write whatever code(s) they want, but it is the coder's responsibility to interpret the actual words into codes, even if those codes are different that what the physician pre-selected. You can't change the actual diagnosis, but you can change the diagnosis code, especially if the code is incorrect. The same applies to CPT codes. It the doctor wrote "laparoscopic total hysterectomy" but then put the code for an open hysterectomy, you should select the correct code for the procedure done and documented. If the documented op report states the cologuard was positive, you are in fact coding it accurately and according to the op report if you code as diagnostic vs screening.
2) What a physician writes as "screening" is not always really a screening per coding guidelines. Let's compare it to "consult" - another word with a very different definition from a coding perspective than from a medical perspective. Simply because a clinician writes "Asked to consult by hospitalist for this patient with post menopausal bleeding." does NOT mean it meets the CODING definition of a consult (assuming the carrier even accepts consult codes.) I would only consider a consult E/M if it meets the coding definition.
3) It's best when the coder and clinician have a collaborative relationship. I realize not everyone works for a small practice, and many coders in the same week will code for 50 different clinicians.

Whenever possible, if I see an issue like this, I will shoot a pre-templated e-mail to the clinician. I word it carefully to indicate that I am in no way trying to advise how they should care for their patients. But that rather I am trying to help advise regarding documentation so that we can all ensure proper payment for the services they render. I am here as an experienced coder and reimbursement specialist to use as a reference to help everyone moving forward. I am certain many clinicians would immediately put my e-mail in the trash folder, never give it a second thought, and keep doing what they always did. There are some who will ask for more information, or check with me weeks later asking if they have improved. Over the years, I have had several physicians who appreciated the education and information that I could provide. Oftentimes they go through 15+ years of training, and no one ever explains to them about basics of wRVUs or bundling. Many physician contracts base reimbursement or bonuses on things the clinician does not even fully understand. If I can educate them that when they round with a resident, unless they properly document their presence and participation, I cannot bill (therefore no wRVU credit), they will gladly remember to add that attestation next time.
 
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