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Back to 45378 vs. G0105

  1. #1
    Default Back to 45378 vs. G0105
    Medical Coding Books
    I was just reading the posts from last week and it came really close to anwering a question I have. It stated that if there is a finding during a screening colonoscopy that CPT 45380 (for example) should be used with the screening diagnostic code first and the polyp (for example) diagnostic code second. This I understand.

    However, the example screening code given (with finding) was V76.51. My question is: Is V12.72 considered a "screening" code. I believe it is. But my physicians and the endoscopy biller disagree. They believe if there was a previous finding that makes the patient "high risk" and that is why they are performing the colonoscopy, then V12.72 should not be considered "screening"and we should not have to follow Medicare guidelines for screening.

  2. #2
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    Greeley, Colorado
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    If the patient has a history of polyps (V12.72) but no current complaints, then V12.72 should be coded with G0105 as they are at high risk. V12.72 qualifies as the "screening" dx for G0105.
    Lisa Bledsoe, CPC, CPMA

  3. #3
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    Thank you! Your reply supports my thoughts on this.

    Kay Ruhe, CPC, CCS-P

  4. #4
    Default 45378 vs g0105
    Here's the LCD for colorectal cancer screening. Check out the area for limitations and indications. It lists everything there.

    http://www.cms.hhs.gov/mcd/results_i...nge=4&retired=

  5. #5
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    Quick question. Are you asking can the V12.72 code be used if the screening converted to a proc w/findings?

    Like this example:

    PT came in for a CCS high risk:

    G0105 dx-V12.72

    but there were findings so:

    45380 dx 1 v12.72
    dx 2 211.3

    I believe the answer there would be no, you would still have to use the
    V76.51, I'm not 100% on that though. But if you are asking can the V12.72 dx be used with the G0105? Big yes!!!!

    Lisa, does the V12.72 still qualify as a screening code if it converts? I would think you would use the actual V code that demonstrates it was a colon screening (V76.51).

    After speaking with a coworker of mine, she says she has seen different insurances want it different ways. Tricare for instance doesn't even want to see the conversion, either code it as a CCS or a diagnostic.

    I'm now curious to see what others think.

  6. #6
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    Greeley, Colorado
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    Quote Originally Posted by coachlang3 View Post
    Quick question. Are you asking can the V12.72 code be used if the screening converted to a proc w/findings?

    Like this example:

    PT came in for a CCS high risk:

    G0105 dx-V12.72

    but there were findings so:

    45380 dx 1 v12.72
    dx 2 211.3

    I believe the answer there would be no, you would still have to use the
    V76.51, I'm not 100% on that though. But if you are asking can the V12.72 dx be used with the G0105? Big yes!!!!

    Lisa, does the V12.72 still qualify as a screening code if it converts? I would think you would use the actual V code that demonstrates it was a colon screening (V76.51).
    After speaking with a coworker of mine, she says she has seen different insurances want it different ways. Tricare for instance doesn't even want to see the conversion, either code it as a CCS or a diagnostic.

    I'm now curious to see what others think.
    For Medicare ONLY I would use V12.72/G0105. Other carriers will need to see V76.51 as well as V12.72 (with 45378). MOST insurances are now requiring that the screening dx be on the claim, whether actually linked to the procedure or not (and of course depending on position i.e dx 1, 2, 3...) You need to show that it started out as a screening and became diagnostic.
    Lisa Bledsoe, CPC, CPMA

  7. #7
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    I received a remittance advice from Medicare today where they made the following patient liability:

    G0105 w/V12.72

    Does that indicate that they consider the V12.72 screening?

    The patient had a colonoscopy in '03 with a finding and so they're scheduled in 5 years. This time there was no treated finding.

    Billers I work with believe that this should not be coded this way. They feel that V12.72 should be linked to 45378 because this is the follow-up of a problem. This would be utilizing LCD for Colonoscopy (link in response above).

    My opion is that this is still a screening. But they are correct that my claim would fall into the colonoscopy LCD coding guidelines using 45378 w/V12.72.

    Thanks for input.

    Kay Ruhe, CPC, CCS-P

  8. #8
    Location
    Charlotte, NC
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    534
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    No, if the patient came in for a screening the proc code would be G0105 and V12.72. The pt is high risk (G0105) due to previous findings (V12.72). The only time you would need to code the 45378 would be if the patient presented with current symptoms but there were no findings. This is for Medicare. However, other insurances don't like the G codes so you would need to use the 45378.

  9. #9
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    Quote Originally Posted by schweppeme View Post
    I received a remittance advice from Medicare today where they made the following patient liability:

    G0105 w/V12.72

    Does that indicate that they consider the V12.72 screening?

    The patient had a colonoscopy in '03 with a finding and so they're scheduled in 5 years. This time there was no treated finding.

    Billers I work with believe that this should not be coded this way. They feel that V12.72 should be linked to 45378 because this is the follow-up of a problem. This would be utilizing LCD for Colonoscopy (link in response above).

    My opion is that this is still a screening. But they are correct that my claim would fall into the colonoscopy LCD coding guidelines using 45378 w/V12.72.

    Thanks for input.

    Kay Ruhe, CPC, CCS-P
    There are guidelines as to how frequently the patient can have the procedure. Off the top of my head I'm thinking 10 years for non-high risk and 2 years for high risk. So if it's been less than 2 years since the last colonoscopy (for the high risk patient) then Medicare is not going to cover it.
    Lisa Bledsoe, CPC, CPMA

  10. #10
    Location
    Charlotte, NC
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    534
    Default
    3 years for high risk with Medicare.

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