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Polyp w/screening colonoscopy

  1. #21
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    I've edited my long initial reply to this:

    Screening may be the primary code for the colonoscopy but it was the discovery of the polyp/possible neoplasm that led the specimen to be sent to Pathology. The primary code of for the specimen is not screening because abnormal tissue has been identified. It would be a screening if there were no detectable abnormalities.

    I suspect few patient's get referred to specialists for screenings without any symptoms. The same is true of surgical pathology specimens. Removing seemingly healthy tissue would not be medical necessary. Removing some cells, as in a pap smear, is different from a surgical procedure and that is not a surgical pathology specimen. It is also interpreted rather than diagnosed and that is why it arrives with a screening code attached and that primary code does not change.

    Surgical pathologists are referred specimens that have clinical indications other than screening.
    Last edited by whaleheadking; 08-27-2010 at 07:42 AM.

  2. Default
    a little late to chime in but I agree with tomtom and the others who have stated it this way.
    The ICD-9 guide declares the “testing of a person to rule out or confirm a suspected diagnosis [for example, cancerous colon polyp] because the patient has some sign or symptom [for example, polyp] is a diagnostic examination, not a screening.” {ICD-9-CM Official Guidelines for Coding and Reporting, Oct. 1, 2009, pg. 73} Therefore, the pathologist is to report the ICD-9 code that corresponds to his/her examination findings as the primary diagnosis on the claim, even though the tissue was obtained during a screening procedure; however, should the pathologic exam fail to yield a definitive diagnosis, the pathologist should report the sign or symptom (e.g., 569.89 or 569.9 or polyp, etc) as the primary diagnosis on his/her claim and not the V-Code for screening.

  3. #23
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    Quote Originally Posted by bgilmore View Post
    a little late to chime in but I agree with tomtom and the others who have stated it this way.
    The ICD-9 guide declares the “testing of a person to rule out or confirm a suspected diagnosis [for example, cancerous colon polyp] because the patient has some sign or symptom [for example, polyp] is a diagnostic examination, not a screening.” {ICD-9-CM Official Guidelines for Coding and Reporting, Oct. 1, 2009, pg. 73} Therefore, the pathologist is to report the ICD-9 code that corresponds to his/her examination findings as the primary diagnosis on the claim, even though the tissue was obtained during a screening procedure; however, should the pathologic exam fail to yield a definitive diagnosis, the pathologist should report the sign or symptom (e.g., 569.89 or 569.9 or polyp, etc) as the primary diagnosis on his/her claim and not the V-Code for screening.
    The problem I am having is that if it is ordered as a screening, then there is no complaint or signs or symptoms so that guideline does not apply, the guideline for screening applies that states if the purpose of the procedure is screening the screening remains the first listed dx regardless of the findings or any subsequent procedure. You cannot change horses mid stream, if it was screening as the intent then it is screening all the way through. The finding of the polyp is incidental and must be reported secondary. The patient had no complaint and no symptoms and we cannot communicate that the did, what they have is an incidental finding that needs further study and the pathologist needs to reflect this as well so that any benefits the patient has stay intact. It is not fraud either, since there was no reason to suspect that anything would be found.
    I understand what everyone is saying but I am presenting it in a different light, the guideline you are referencing states:“testing of a person to rule out or confirm a suspected diagnosis [for example, cancerous colon polyp] because the patient has some sign or symptom [for example, polyp] is a diagnostic examination,...."
    Which is true for a diagnostic study, but in the scenario of a screening there is no reason to suspect anything and there are no signs or symptoms..

    Debra A. Mitchell, MSPH, CPC-H

  4. #24
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    The confirmed polyp is the sign and symptom. This is not a "screening polyp." It is abnormal tissue submitted for pathologic exam and diagnosis. This 88305 is Polyp, colorectal, not Colon, biopsy. The clinical dx on the referral form should be "polyp" because that is what it is.

    The colonoscopy by the clinician should be coded as you have described per ICD-9-CM.

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    I see both views on this. The problem I have with reporting only the 211.3 is that the insurance companies do not make patients aware that if there is a polyp found, their service is no longer covered at 100%. Most policies state that a screening colonoscopy is covered at 100% for preventative purposes but never mention if something is found, you are responsible. In fact, many insurances tell the patient if the claim is resubmitted with a screening code as primary, they will reprocess under the screening guidelines. It seems unfortunate that if a screening pap smear shows a positive result, the patient is still entitled to screening benefit, yet a patient who has an incidental finding of a polyp is now responsible for a deductible and a coinsurance. I think it is time for the insurance companies to clarify their position on this.
    Last edited by rere500; 09-23-2010 at 04:35 AM.

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    http://www.cms.gov/ColorectalCancerScreening/

    I have also read a MLN Matters article specifically stating how to bill a screening colonoscopy when polyps are found and removed. It states that, because you can't use the G0105 or G0121 when a polyp is removed, they (Medicare) still want the V76.51 on the claim and "pointer" 1 BUT to attach the 211.3 to the procedure (45380/45385 etc). Their reasoning was due to deductibles and coinsurance that applied to the screening colonscopy, but now that this is all going to change and Medicare is paying 100% on all eligible screening tests, I am not sure that this guideline with be invalid. I am looking for this article, I will post a link once I find it.
    Last edited by Stefanie; 10-15-2010 at 12:38 AM. Reason: Added comment



    Stefanie Cramer, CPC
    Independent Contractor
    Medical Coding and Consulting
    Cramer Consulting

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    Stefanie Cramer, CPC
    Independent Contractor
    Medical Coding and Consulting
    Cramer Consulting

  8. #28
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    Jan 1, 2011, CMS is waiving the deductible for colorectal screenings that become diagnostic. See the "Coding Edge", December 2010 article, pg 8.

    Go to cms.gov/apps/media/fact_sheets.asp
    click "November 02, 2010" link
    click "Final 2011 Policy, pay changes In Medicare Physician Fee Schedule"

    "Elimination Of Deductible And Coinsurance For Most Preventive Services: Effective Jan. 1, 2011, the Affordable Care Act waives the Part B deductible and the 20 percent coinsurance that would otherwise apply to most preventive services. ... The Affordable Care Act also waives the Part B deductible for tests that begin as colorectal cancer screening tests but, based on findings during the test, become diagnostic or therapeutic services."

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