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Screening vs diagnostic

  1. #1
    Default Screening vs diagnostic
    Medical Coding Books
    This must be the question of the year. Can as many people reply to this from the professional billers side only (not asc) How is everyone coding for private insurance companies only, when a screening colonoscopy is started and a biopsy or polyp is removed during the colonoscopy.

    There is no set policies for bc/bs, uhc or aetna, some state they follow medicare guidelines, others do not.

    I would love to know if most are coding as a G0105/G0121 or as a 45380/45384/45385 ???????

    With the icd-9 as the polyp .

    Thank you
    Last edited by KIMBERLY44; 05-10-2009 at 04:41 PM.

  2. #2
    Greeley, Colorado
    We do not use the G codes for anyone but Medicare and thank heaven they are clear on how to code the screenings turned diagnositc. As for commercial: I code dx 1 V76.51; dx 2 211.3 and link 2,1. HOWEVER...the PM system we use flips the codes so in both the diagnosis box and on the line item it appears 211.3, V76.51. I have a major problem with this PM system and they will not fix it without charging us uness I can prove other carriers are following Medicare on this.
    Lisa Bledsoe, CPC, CPMA

  3. #3
    The private companys accept the "g" codes and apply any preventative benefit. Thats the problem, the patients want to use their preventative benefit, but it ends up being diagnostic.

  4. #4
    Cape Girardeau
    I understand the patient wanting to use their preventative benefits, but the op note says that they removed a polyp, then it is not a screening anymore. So would it not be illegal to bill as such? I would suggest informing the patients that it would be a screening, but if the surgeon does anything then it is no longer a screening.

    I know with my personal insurance a screening colonoscopy is covered and 100%, but if the surgeon does anything else, then it applies to my deductible. So I truly understand where patients would want it billed as a screening, but I still feel that would not be legal.

    A few years ago (before preventative medicine was practiced) when the patient had a screening colonoscopy done insurance would not pay. The patients would call wanting us to change the diagnosis. This was always explained that the surgeon did not dictate the procedure that way and it is illegal. The notes stated that the patient needed a screening colonoscopy and the colon was normal. It was just out of our hands.

    Isn't it funny how it has changed?

  5. #5
    Here is some food for thought: Look at the ICD-9-CM Official Guidelines for Coding and Reporting at, on page 71, and note that in the Screening section, it states: "A screening code may be a first listed code if the reason for the visit is specifically the screening exam." Additionally, this same section states "Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis."
    Jenny Berkshire, CPC, CEMC, CGIC

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