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colon vrs screen

  1. Unhappy colon vrs screen
    Medical Coding Books
    We had an outside company do a coding audit and we were dinged on the following. On the Operative report the doctor states that patient presents for a diagnostic colonoscopy. History of family cancer. We were billing these as a screening - G codes. They said that this should be billed 45378 with the v code. We have contacted the Doctors office that do these and they insist that this should be a screening. On the scedule sheet they state that it is a "recall" which to them is screening. We have told them that in order for us to bill any procedure as a screening in must state this some place on the chart or Op Recport. Am I correct? By the way I work in an ASC. We were also using the G codes for all of our payers and they have been paying, we also got dinged on that. Any feedback would be helpful.

  2. #2
    Charlotte, NC
    To me this sounds right. If the doctor states diagnostic, there's a code for that, 45378. If the patients presents with a problem, it's diagnostic. If they are there for a screening due to family or personal hx or age "requirements, then the doctor should be stating that in the documentation.

    Of course, depending on the insurance, you can still use the 45378 code even if stated as a screening because some insurances don't recognize the g-codes, even for an ASC. ( I work in one too and it's getting ridiculous figuring out which private insurances want what)

    But even if you use a 45378, the doctor should still state "screening".

  3. Default
    I work on the doctor side and I would code a screening colonoscopy for family history of colon cancer regardless of the dictation of 'diagnostic' by the physician. If the patient is asymptomatic and presents for the procedure due to a family hx of colon Ca, then that is a screening colonoscopy. You cannot bill a 'diagnostic' test without a symptom to diagnose. I would assign the appropriate CPT/HCPCS as per the payor request. Medicare would require G0105 for high risk screening, 45378 for most commercial payers. I personally would challenge the audit.

  4. Default screening vs diagnostic colonoscopy
    The question that we have is when a patient is scheduled for a screening colonoscopy, but the doctor finds and removes a polyp. We have been told to bill this as screening using the V code for screening as the primary diagnosis because that is the indication for the procedure and then the code for the finding (ie polyp) as the secondary code. Is this correct or is a screening colonoscopy no longer screening when a problem is found? Does anyone have a source that would help us with this?
    Any help on this would be appreciated!

  5. #5
    knjngn- I am not sure if your question is a clarification to the original posted by jackiefrye or if it is a new one so I will respond to both.

    When a screening colonoscopy is performed and a polyp is removed, the V76.51 is still the Primary diagnosis if it is a Medicare patient. If it is not Medicare than it is the 211.3 or 569.0 unless you follow Medicare guidelines for all payers. I found this in Medicare Part B News Online 10/20/2008.

    jackiefrye- it sounds like your physician might need to change the way s/he words the procedure. It sounds like the same doc is stating in the note that it is diagnostic but then is verbally saying it was screening. Coding has to represent the documented op note so in this case I would ask for an addendum. If the doc stated that was diagnostic, did s/he not state the sign or symptom?


  6. #6
    knjng - According to coding guidelines in ICD-9 polyp should be listed as 2nd dx and V code should be listed as primary dx.

  7. Default
    1. I would look at the audit again. Review the LCD Medicare Guidelines for billing screening versus diagnostic colonoscopies. Medicare likes G codes with V codes but most private payers like 45378 with V codes. Each insurer may have a different rule for V codes. Anything you got "dinged" on should be reviewed against the that particular carriers policy for coding screening colonoscopies and how they define the selected "v" code. You cannot apply one rule across the board.

    2. Regarding the coding of a screening diagnosis when a polyp is removed for Medicare: see MLN Matters SE0746

    Code Screening code as primary diagnosis and polyp as second diagnosis, but reference second diagnosis and then in Item 24E (Diagnosis Poniter) enter "2" to link the procedure with the abnormal finding (eg. polyp).

    We actually had to have our practice management software vendor "fix" our charge entry to be able to specify the 2nd diagnosis as the correct linked diagnosis for the procedure.

  8. #8
    Columbia, MO
    The correct coding guidelines greated by the CDC and cooperating parties state that if the reason for the procedure is screening then the first-listed diagnosis code remains screening regardless of the findings or any subsequent procedure performed as a result of the findings. This is a guideline not set out for Medicare but for all users of ICD-9. These guidelines can be found at the website for the CDC's data warehouse for ICD-9. Individual payers can determine how the will cover certain procedures for their beneficiaries but that does not govern how we code. If the payer does not cover screening, the patient is then responsible.

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