Screening colonoscopies


West Columbia, SC
Best answers
Our office is having a problem when trying to transmit claims to our local BCBS and other insurance companies for colonoscopies that initially are scheduled as screening and during the procedure the doctor finds a polyp and removes it. Per ICD-9 guidelines we are to file with the screening diagnosis as primary and the polyp as secondary. We try that but the insurance company edits wont take the claim that way due to the CPT code for the polyp removal.

We have been filing it then with the polyp diagnosis as primary but then after the claim pays we have to initate an appeal for adjustment which seems to be the wrong way to do this when all the information I have says the insurance companies are to allow usuage of the screening code as the primary diagnosis.

Thanks for your help.

Doug Williams, CPC
You need to have your computer software set up a little differently. You need to have your diagnosis pointer point to diagnosis two instead of one. That way you can put your screening as the first diagnosis and polyp as the second but the procedure actually "points" to the second diagnosis. What it would look like on paper is in box 24 E on the HCFA instead of having a one there it would just say 2. If I have totally confused you let me know and I will try to explain it a little better. Hope this helps!

I code for 2 colorectal surgeons and whenever they do a screening scope and find something, I code what the findings were. Under the guidelines, it says that isthe pt. has a sign or symptom, it becomes a diagnostic exam, not a screening exam.
It also says that the condition MAY be coded as a secondary, not that it HAS to be.
Hope that this helps!

BC of AL's has a provider manual that states the findings may be coded as primary for screening procedures.

You can have your system set up as scorrado suggested, which is the way Medicare has published it to be done. Medicare published their guidelines in Oct or Nov 07 explaining, clarifying how it should be done. Per MC, if it started as a screening, the primary diagnosis should be screening.

For BC, it is always complicated. You get into the problem where does the patient's insurance cover it. If you code it as a screening, and they have already had a preventive exam, BC will not pay. But the patient's policy may cover it 100% as screening and if coded as diagnostic the patient may have a copay.
For BC, our office policy was to code the polyp (as diagnostic) primary and screening secondary. If the patient calls in and states it was a screening we appeal the claim that it was a screenig with a finding, but due to their statement in their policy manual we code as diagnostic.
However, it is done, it needs to be part of your policy/compliance plan.

For sundaey's reply, Medicare specifically states otherwise due to the patient's do not have to pay deductibles on screening colonoscopies. Other insurance companies, do the same thing, if it is a screening they pay 100%. You get back to if it started as a screening, should it remain as a screening.
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