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Screening Cscope vs UHC

  1. #1
    Angry Screening Cscope vs UHC
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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?

  2. #2
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    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.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
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    I would have coded 45378 V12.72. I don't see how you can code screening if the patient already has a history of colon polyps.
    Lisa Bledsoe, CPC, CPMA

  4. #4
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    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.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    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...
    Lisa Bledsoe, CPC, CPMA

  6. #6
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    Quote Originally Posted by Lisa Curtis View Post
    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...
    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.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7
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    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.
    Susie Corrado, CPC
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  8. #8
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    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.

    Debra A. Mitchell, MSPH, CPC-H

  9. #9
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    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.

  10. #10
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    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.

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