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Patient furious about screening turned diagnostic colonoscopy

  1. #11
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    Columbia, MO
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    Medical Coding Books
    Quote Originally Posted by KBOVA View Post
    I do not agree with those that would indicate a screening dx can primary when the patient has active GI s/s that would prompt the doc to do a colonoscopy to investigate. The screening portion of the ICD9 book makes it very clear that screening can only be the primary dx in in patients without presenting s/s.
    My point is.. and I have seen this happen.... The patient arrives for their colonoscopy which they have scheduled as a screening per prompting from their physician, the Doctor now asks the patient about prior symptoms, " have you experienced any...., have you had any instances of....." and the patient answers honestly that yest this, and that have existed... these are not presenting symptoms, and do not change the exam from a screeing. The patient has answered specific questions in an honest and direct fashion without indicating that this is why they wish to have a diagnostic study. The patient gets to control this and they have requested a screening. If the physician feels a diagnostic study is in order then the patient needs to be informed of this so that they may think it over and agree. When you wrote the permit for the study did you indicate that the patient was consenting to a screening colonoscopy or a diagnostic? Your permit must be specific if it is generic, patient consents to colonoscopy, then the patient decision that this was screening stands.

    Debra A. Mitchell, MSPH, CPC-H

  2. Default
    Quote Originally Posted by mitchellde View Post
    My point is.. and I have seen this happen.... The patient arrives for their colonoscopy which they have scheduled as a screening per prompting from their physician, the Doctor now asks the patient about prior symptoms, " have you experienced any...., have you had any instances of....." and the patient answers honestly that yest this, and that have existed... these are not presenting symptoms, and do not change the exam from a screeing. The patient has answered specific questions in an honest and direct fashion without indicating that this is why they wish to have a diagnostic study. The patient gets to control this and they have requested a screening..
    ...And this is exactly what is happening in my doc's case. He wouldn't be doing his job if he didn't quiz the patient right before the procedure as to why that patient is there for the procedure, especially in the cases where that patient has NOT seen the doc yet.

    Quote Originally Posted by mitchellde View Post
    When you wrote the permit for the study did you indicate that the patient was consenting to a screening colonoscopy or a diagnostic? Your permit must be specific if it is generic, patient consents to colonoscopy, then the patient decision that this was screening stands.
    It states that the patient understands that what is starting out as screening may end up as diagnostic (polyp, bleeding AVM, etc.), and thus may change what/how the insurance is paying. We implemented this permit BECAUSE of the patient mentioned above.

    ...And this whole thread? You can see why there is contradictory information out there...there is contradictory information in this thread itself. Unfortunately, when doing a google search, it is contradictory, also.

    Thanks to those who have tried to help.

  3. #13
    Location
    Everett, WA
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    I have been watching this thread with extreme interest and it appears there is no absolute determination, or is there? Depending on who would "audit" this scenario there is a possibility either could be correct? Ultimately, who or what would be the final authority? Anything in the works from AMA or MCR to help resolve such cases? Just a thought-- perhaps a lawyer is needed for interpretation?

    Glad this thread was posted..

    ---Suzanne E. Byrum CPC

  4. #14
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    Quote Originally Posted by trinacmt View Post
    ...And this is exactly what is happening in my doc's case. He wouldn't be doing his job if he didn't quiz the patient right before the procedure as to why that patient is there for the procedure, especially in the cases where that patient has NOT seen the doc yet.



    It states that the patient understands that what is starting out as screening may end up as diagnostic (polyp, bleeding AVM, etc.), and thus may change what/how the insurance is paying. We implemented this permit BECAUSE of the patient mentioned above.

    ...And this whole thread? You can see why there is contradictory information out there...there is contradictory information in this thread itself. Unfortunately, when doing a google search, it is contradictory, also.

    Thanks to those who have tried to help.
    Yes you are tell the patient this procedure will START OUT AS SCREENING but MAY become diagnostic if there are findings. What you then did was indicate the procedure was never screening and started out as diagnostic due to presenting symptoms, which as I am understanding is not true. The patient was asymptomatic on presentation and merely indicated symptoms had been present in the past. This is clearly screening and should be listed with the V code for screening first. The 33 modifier (PT for Medicare) will then be used if a diagnostic procedure had to be performed due to findings.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    We just went through this in our office and we found in the "medical practice coding pro" and verified this on the medicare site in their policy manual the following:

    This was the question posted:

    "frequently, the primary care physician will refer patients for "colonoscopy screening" when in fact the patient is having gi symptoms that mean the patient should have a diagnostic colonoscopy instead. After the patient comes in for an office visit with our gi doctor and the colonoscopy is scheduled, can the colonoscopy be billed as diagnostic even though the pcp ordered a "screening"?"

    this was the answer posted:

    " the medicare benefit policy manual states that when an interpreting physician determines an ordered test is clinically inappropriate or suboptimal, and a different test should be performed, " the interpreting physician/testing facility may not perform the unordered test until a new order form the treating physician/provider has been retrieved". In other words, the gi doctor can contact the ordering physician and explain why a diagnostic study is more appropriate.....unless the gastro asks the original physician to change the order for the test, you are really stuck doing the screening requested, according to medicare policy."

    after much searching, i did verify this with the medicare policy to be correct. If a patient is referred for a screening and they state symptoms, you can see them and treat for the symptoms but the colonoscopy has to be billed as a screening primary and any diagnostic findings secondary.
    Sheila DiGangi,CGCS
    Certified Gastroenterology Coding Specialist
    Bayfront Digestive Disease Associates
    100 Peach St. Ste 200
    Erie, PA 16507
    814-456-7733 Ext. 117
    814-456-7213 Fax
    sdigangi@bayfrontgi.com

  6. Default
    I used to work for a General Surgeon. We had this problem with patients all the time. They would go in for a screening. If the surgeon found a polyp and removed it, the procedure would turn diagnostic. I had many patients say they went in for a screening and that was what they consented to. I always had to explain that the physician would not just leave a possibly cancerous polyp while doing the scope.

  7. #17
    Location
    Columbia, MO
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    Quote Originally Posted by nc_coder View Post
    I used to work for a General Surgeon. We had this problem with patients all the time. They would go in for a screening. If the surgeon found a polyp and removed it, the procedure would turn diagnostic. I had many patients say they went in for a screening and that was what they consented to. I always had to explain that the physician would not just leave a possibly cancerous polyp while doing the scope.
    Yes but this is different, this was a screening that became diagnostic and the operative permit must have contained a phrase for this this such as consent for screening colonoscopy with possible biopsy or polypectomy as necessary. If this is not there then you cannot perform the diagnostic portion, also the screen V code is still the first listed code with the findings secondary. The original poster though is a bit different scenario, this patient arrived for a screening filled a permit out for screening and then was coded as though it were a diagnostic exam based on the answers to questions regarding the past presence of symptoms. This cannot be done, it is always screening first listed with finding secondary, when the patient is requesting a screening test.

    Debra A. Mitchell, MSPH, CPC-H

  8. Default Its a screening
    This is a screening no matter what- if it was ordered as a screening then it is a screening,
    go by the referring physician's order, pts. will elaborate on GI symptoms but the referring
    physician is the one ordering the procedure and he ultimately wanted a screening
    done..
    Linda L. Jackson, CPC-CGIC

  9. #19
    Thumbs up
    I agree with it being screening. The intent is what decides the procedure. Here the intent is screening and so should be the code.

    Girish Dadhich, CPC

  10. Default
    Wow! Good to know we are not the only practice whose patients scream.

    If we can't agree in this forum, how do we can expect patients to understand. PCPs do not get it either. They will send a patient for Screening (V76.51) when in fact the patient is Surveillance (Personal Hx Polyps, V12.72). Screening and Surveillance are not the same thing. For example, UHC defines a patient with a personal history of polyps as surveillance due to the increased frequency of colonoscopy and not covered under the Affordable Care Act Colon Screening benefit. This type of colonoscopy is covered under their regular benefits, not 100% screening. Many insurance companies have caught on and are now adding these medical policies. This means that for many companies only patients 50+ with no history, no symptoms, and no grandfathered health plan will receive a 100% paid colonoscopy.

    To help solve this issue, we have patients read and sign a colonoscopy waiver before check in and a Colon Notification Form with their anticiapted CPT/Dx codes informing them to call their ins companies to determine their benefits. They are on our website under patient forms, www.atlantacolon.com. It has reduced our billing calls by at least 50%.

    Anna Barnes, CPC, CEMC, CGSCS

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