Wiki Screening colonoscopy/EGD

[dkrisak]

Cigna is denying 100% coverage on an EGD done the same time as a screening colonoscopy because V76.51 is the principal diagnosis on the claim. Otherwise, they say it would be covered 100% without a enormous co-pay by the patient. Has something changed recently? We have always billed these together in the past with no problem. Can I move the principal down to a secondary spot and use the reflux esophagitis as a principal instead?

thanks!

 

[lace659]

Was the purpose of the EGD for screening or was that diagnostic? It will make a big difference. If it was intended as a screening, then it needs to be submitted with a screening dx (drilled in my head by my old compliance manager - a screening is a screening, period.). If only the colonoscopy was the screening and the EGD for the esophagitis, then yes, I would change it to become the primary dx for the EGD. Otherwise I would quiry the provider for a reason for the EGD other than V76.51.

 

[mitchellde]

V76.51 is not medical necessity for an EGD. If the patient requested a screening colonoscopy due to meeting age related criteria and is not symptomatic then it is appropriate to use the V76.51 first listed and linked to the colonoscopy only. The question I believe the payer has is legitimate, that is how do you have an asymptomatic patient and a symptomatic patient at the same encounter. So to perform a screening procedure at the same time as a diagnostic procedure performed for symptoms is contradictory. However if you have the documentation to support an symptomatic colonoscopy screening and a symptomatic issue that has no bearing on the colon screening then theoretically you should be able to to both, but make sure your dx codes are properly linked.