Wiki Screening Cscope vs UHC

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slpagel

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Pt came for a screening Cscope. He has a history of polyps V12.72. The claim was submitted with G0105 for the CPT and V12.72. United Healthcare is claims that this is diagnostic. Has anyone else have this problem?
 
you need a V code for the screening to be first listed. the scope was performed for screening purposes not for the hx of polyps this will cause it to be processed as screening.
 
It can still be screening it is just you have a high risk patient, but with no complaints in an asymptomatic patient it does look like screening. Just because you find polyps once does not mean there will always be polyps. We always coded screening for the routine return colonoscopies in the cancer center it was never a problem. we used the screening code first and the personal hx code second.
 
So you would code V76.51 then V12.72?

According the the ICD-9 Coding Guidelines: "Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may requires continued monitoring...Personal history codes may be used in conjunction with follow up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure".

My interpretation is that the previous medical condition renders this no longer a simple screening. I welcome any other interpretations that may or may not change my point of view... :confused:
 
Lisa Curtis said:
So you would code V76.51 then V12.72?

According the the ICD-9 Coding Guidelines: "Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may requires continued monitoring...Personal history codes may be used in conjunction with follow up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure".

My interpretation is that the previous medical condition renders this no longer a simple screening. I welcome any other interpretations that may or may not change my point of view... :confused:
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But this is not a followup exam for the polyps that were removed it is a screening for the colon as a whole. The patient is well, with no problems, the colon consists of several parts which must all be screened. I still see this as screening, and yes I have used the V 76.x codes with V10.x-V12.x codes many times. It is a screening for a patient that has had polyps removed in the past. It indicates a higher risk but still screening.
 
I agree with Lisa. If the pt has had polyps they are at higher risk of having polyps in the future and need to have colos sooner than other people. This is the reason you are doing the colo. If it was just 'screening' then they would need to be seen every 10 years. How do you justify coding v7651 when they are having there colos every 2 years or 5 years? If they are high risk you need to use a "high risk" dx code.

I always code the way you do Lisa - I totally agree with you. You may have patients that do not get to use their screening benefit because of the code that you have used, but coding to get paid or avoid a conflict with a patient is unethical.
 
I agree coding for payment is unethical, it is something I would never even suggest. I still see this as a screening for a patient with a hx of polyps. It is the way we did it at the cancer center always. If a patient had breast cancer and has a screening mam for the surviving breast then it is a screening V code with a hx of breast cancer. I see this no different. So I guess it is an interpretation issue. The problem is the patient is at the heart of our interpretations.
 
I agree with Debra. It is good to put V76.51 and then V12.72 for 45378 to let them know it is for screening and of course high risk too. It more explanatory to the insurance. I mean there is nothing wrong if we put both. We also see denials if we don't put V76.51 along with V12.72 for 45378.
 
From what I've been seeing in daily life w/UHC as well as other carriers, they want the V76.51 listed first followed by the V12.72. They want to see it as a screening and then why.

The G-codes do not have to be used so you use the 45378 but then the payor doesn't know it is a screening so you put the V76.51 first then follow it up with the V12.72 to show high risk and the medical necessity for a screening sooner than normal.

Hope this helps.
 
mitchellde said:
I agree coding for payment is unethical, it is something I would never even suggest. I still see this as a screening for a patient with a hx of polyps. It is the way we did it at the cancer center always. If a patient had breast cancer and has a screening mam for the surviving breast then it is a screening V code with a hx of breast cancer. I see this no different. So I guess it is an interpretation issue. The problem is the patient is at the heart of our interpretations.
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But the surviving breast is not the one that had the cancer...
It does seem to be an interpretation issue. While I agree that the patient is the priority, the real issue in our job is the correct coding. And, as we all know, coding is quite often open to interpretation and can be subjective. :eek:

coachlang3 - as far as what the insurance "wants" doesn't mean that it is correct coding. How often do the insurance companies tell patients that the doctors office coded the visit "wrong" when we really coded it right?
 
I disagree with the comment that this is the way that the insurance wants it. Coding screening (v7651) is the way to code a colonoscopy so that it will get paid and there is no conflict with them or the patient. When I code V1272 as primary I do not get denials. I get deductible issues or 80/20 payment. But they are not denials. But as a coder I cannot in good faith code a patient who has a history of colon polyps or colon cancer as screening. I have to code the reason they are having the procedure and that reason is history. What do you do when a patient has Medicare and they have a hx of colon polyps and it has been two years since their colo? If you code V7651 with G0121 it will get denied for frequency because that can only be used every 10 years. The proper way to code it is V1272 with G0105.
Obviously we should all just agree to disagree on this one! LOL! The life of a coder. Now my big question -what are we going to do when we have a patient who has Medicare secondary and their primary payer recognizes consult codes next year? Do we bill the consult code or not?
 
I agree Susie - we may have to agree to disagree.
As for the consultation issue...man - I for one wanted them gone, but not just by CMS. If they can't be completely gone, then leave it alone and we'll just keep working with the providers on the documentation requirements! Now it's opened this whole new can of worms!
 
scorrado said:
I disagree with the comment that this is the way that the insurance wants it. Coding screening (v7651) is the way to code a colonoscopy so that it will get paid and there is no conflict with them or the patient. When I code V1272 as primary I do not get denials. I get deductible issues or 80/20 payment. But they are not denials. But as a coder I cannot in good faith code a patient who has a history of colon polyps or colon cancer as screening. I have to code the reason they are having the procedure and that reason is history. What do you do when a patient has Medicare and they have a hx of colon polyps and it has been two years since their colo? If you code V7651 with G0121 it will get denied for frequency because that can only be used every 10 years. The proper way to code it is V1272 with G0105.
Obviously we should all just agree to disagree on this one! LOL! The life of a coder. Now my big question -what are we going to do when we have a patient who has Medicare secondary and their primary payer recognizes consult codes next year? Do we bill the consult code or not?
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I NEVER let coverage issues cloud my coding. I think that is the problem with some of the issues in a lot of offices I have been in. I am sorry to be the big thorn here but I still firmly feel this is by definition a screening. Irregarless of the frequency there is no diagnostic purpose for this exam it is for the purpose of screening. So no matter if the patient has screening benefits or has to pay a deductible, my concern is always correct coding. I go back to the patient is here for screening due to a hx of polyps. Sorry ladies I go on record as big disagreement.
 
Debra - I admire your stance and appreciate your input. I feel strongly about my opinion/interpretation as well. We have to stand up for what we believe in life and in our work. Shows passion! :)
 
The valuable piece of information that was given to me by the insurance company is that the rule of thumb is that in a patient with no history of any colon problems may have a screening colonoscopy every 10 years. In a patient that has or had a polyp (or any other condition pertinent to the colon), may have a screening colonoscopy perhaps every 2-3 or every 5 years BECAUSE they are at higher risk. If they are returning for the study at their physician's urging and not because they have pain or bleeding or any other symptom, it is a screening study.

Much of the coding heirarchy is very ambiguous and it puts us in a very confusing position (most times).

Sometimes, we not only have to change or hats daily but we have to change glasses to see things in different lights.

Good luck all
 
Debra,

Out of curiosity I would like to know how you code a Medicare pt who has a history of colon polyps and their last colo was 5 years ago? As previously stated in my earlier post you can't code that with v7651 and G0121. It will be denied. It has to be coded v1272 and G0105.
 
AuntJoyce said:
The valuable piece of information that was given to me by the insurance company is that the rule of thumb is that in a patient with no history of any colon problems may have a screening colonoscopy every 10 years. In a patient that has or had a polyp (or any other condition pertinent to the colon), may have a screening colonoscopy perhaps every 2-3 or every 5 years BECAUSE they are at higher risk. If they are returning for the study at their physician's urging and not because they have pain or bleeding or any other symptom, it is a screening study.

Much of the coding heirarchy is very ambiguous and it puts us in a very confusing position (most times).

Sometimes, we not only have to change or hats daily but we have to change glasses to see things in different lights.

Good luck all
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EXACTLY it is screening not diagnostic.
 
How can you code V7651 with G0121 every two to five years when a patient has a history of colon polyps when Medicare only pays for that every 10 years? If you are getting paid for this combination please let us in on the secret because I have never had a screening colo paid any sooner than 10 years by Medicare.
 
slpagel said:
Pt came for a screening Cscope. He has a history of polyps V12.72. The claim was submitted with G0105 for the CPT and V12.72. United Healthcare is claims that this is diagnostic. Has anyone else have this problem?
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On the Left Coast, we only use the "G" CPT codes when billing Medicare. Do you have a contract with United? If so, go to their website or call them for guidelines as to their preference when billing screening Colo claims. Most of our contracted carriers will tell us the order they prefer the DX codes for screenings. Much luck to you...
 
scorrado said:
How can you code V7651 with G0121 every two to five years when a patient has a history of colon polyps when Medicare only pays for that every 10 years? If you are getting paid for this combination please let us in on the secret because I have never had a screening colo paid any sooner than 10 years by Medicare.
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I never intimated that Medicare or any other payer paid this I stated I felt this was the appropriate way to code it based on the information that the patient was here for screening due to a hx of polyps. Payment will be based on medical necessity and benefits.
 
I guess what I am looking for is documentation to tell me that a history of equates to screening and therefore the history code is second... I can't seem to wrap my mind around the fact that screening can be performed on someone with a history of polyps since said history is the true reason for the procedure. I truly appreciate everyone's input here! I want to code these the right way!
 
I love reading everyone's opinion on this issue also. We are all very passionate about what we do that is obvious so I guess that means we are in the right jobs. LOL!
 
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