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V76.51 vs V12.72 Primary

  1. Question V76.51 vs V12.72 Primary
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    If a patient comes in for a screening colonoscopy with a personal history of polyps, and the commercial payer specifically states the V12.72 will cause the claim to process as a diagnostic, not screening procedure, is it appropriate to code the V76.51 primary and
    V12.72 secondary? The coding guidelines state personal history codes can be used in conjunction with 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.

  2. Default
    Here may be the key to the tip you need in determining whether you want to use V76.51 as primary and V12.72 as secondary. History (of) Guidelines also details these terms. Personal history codes explain a patient's past medical condition THAT no longer exists and is not receiving treatment, but that has the potential for recurrence. So I would only use the V76.51 on the claim form so that there isn't any problem with the payor's interpretation and if in doubt ask the payor if the claim would be rejected with the V76.51 as primary and V12.72 as secondary.
    Thanks,
    Brian Hazel CPC-A

  3. #3
    Default
    To follow up on the above with a question:

    We have the doctor amend all their reports to include the indication "screening," but wonder if this is needed since personal and family history of polyp/cancer is technically a screening. Typically, they have a 100% screening benefit, but the doctor only dictates history of polyps (v12.72), for example. The claim will only pay @ 100% with screening (v76.51) primary.

    Thoughts?
    Last edited by Kisalyn; 04-05-2011 at 08:58 AM.

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    We have been dealing with this same issue. You have to watch the payer policies. For example, UHC states that a patient with V12.72 personal Hx polyps is not considered a screening but a surveillance because the V12.72 requires more frequent colonoscopies (2-5 years versus 10yrs). If UHC audited a claim with V76.51 primary and V12.72, it is my understanding they would reprocess as non screening. There are a few companies adopting these rules. Some companies are defining "screening" as a non high risk patient and surveillance as V12.72, V10.05, etc. Surveillance colonoscopies are then processed under regular diagnostic benefits, not screening. I go by the payor policies and pass them on to the patients so they can yell at their ins companies and not us.

    Anna Barnes, CPC, CEMC

  5. Default PT and 33
    We have had a discussion at the GI office I work at concerning pathology billing. Have you ever heard of billing a pathology from a colon with a PT or 33 modifier and a screening code as the primary DX so the insurance will process the pathology as part of what started out as a screen but the MD found a polyp or felt they needed to take a biopsy.

    Thank You for your help

    Ann Rice CPC

  6. #6
    Location
    Pensacola, Florida
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    Default
    Quote Originally Posted by majik1331 View Post
    We have had a discussion at the GI office I work at concerning pathology billing. Have you ever heard of billing a pathology from a colon with a PT or 33 modifier and a screening code as the primary DX so the insurance will process the pathology as part of what started out as a screen but the MD found a polyp or felt they needed to take a biopsy.

    Thank You for your help

    Ann Rice CPC
    We do not attach the modifier to the pathology charges, but for commercial insurances, we do list the
    v76.51 as the primary dx for the path claim.

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    we have had trouble with BCBS processing the colonoscopy as a screening.
    here is my example the patient had a screening and diverticulosis was found nothing was done other that the colonoscopy. We coded it as V76.51 and 562.10 with 45378. However they are processing it as diagnostic because of the secondary diagnosis.
    Anyone have any suggestions?

  8. #8
    Location
    Charlotte, NC
    Posts
    534
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    nabernhardt:
    we have had trouble with BCBS processing the colonoscopy as a screening. here is my example the patient had a screening and diverticulosis was found nothing was done other that the colonoscopy. We coded it as V76.51 and 562.10 with 45378. However they are processing it as diagnostic because of the secondary diagnosis.
    Anyone have any suggestions?
    How old is your pt? To me that is coded perfectly.

  9. #9
    Location
    Pensacola, Florida
    Posts
    275
    Default
    We are in Indiana and I have coded that way for along time, and as far as I know we are not having issues with Anthem. However, after doing some further research on the use of modifier 33, we our now attaching that modifier even if no diagnostic services were performed. Everything we read indicates to attach the modifer if the procedure code is not inherently "screening". 45378 is not a screening CPT code, like G0121 is, so In your case, we would code 45378-33/V76.51, 562.10.

    Bridgette Martin LPN,CPC,CGIC

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