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Patient furious about screening turned diagnostic colonoscopy

  1. Default Patient furious about screening turned diagnostic colonoscopy
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    We have a patient who came in for a 10-year followup colonoscopy (personal history of colon polyps). However, in the MD visit right before the procedure, he made mention of several (MANY) symptoms he had been having, all relating to GI tract.

    I am under the impression that at the point he shared his first symptom, this is no longer a "screening" colonoscopy and instead turned diagnostic. It was billed as such (diagnostic), and surprise surprise, the insurance applied to deductible rather than paid at 100% (which it would have a screening).

    Our patient is livid. He stated that he would not have had the test done for his symptoms and only mentioned the symptoms because "the doctor asked." I explained that because they were documented, that is what I have to code and thus bill by.

    We have actually changed our office policy because of this patient. We now have colonoscopy patients sign a waiver, stating the difference between a diagnostic and a screening colonoscopy, but we are still dealing with the backlash of this one.

    Can someone verify, please, that it was coded/billed correctly as a diagnostic rather than screening as a followup of colon polyps?

    Thank you.

  2. #2
    Columbia, MO
    If the patient related that these these had been symptoms but that he was here for a screening and not currently complaining of anything then it should have been a screening. Having had a symptom and affiming this in response to a question does not make this a reason for an exam.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Even if by looking at the op note (only thing the hospital had to bill by), there is NO MENTION made of screening, only all of these symptoms?

    Yes, I am billing for physician not hospital, but I am curious now.

  4. Default
    The patient schedule is part of the patient's Medical record and if a non-Theraputic Routine colonoscopy was what he scheduled for it should be the primary Dx despite additional claims or findings. your best option now is to ask your physician to amind the medical record with the original reason being added as the primary presenting Dx and file a corrected claim with the insurance. By 2010 CMS guide lines all non-theraputic colonoscopies should be billed routine with histories and findings to follow. Hope this helps

  5. Default
    Everything I have found (prior to this) is indicating just the opposite. I have pages and pages printed from the internet (this site, Medicare site, and others) that say it cannot be a screening if symptoms are listed.

    Where in the 2010 CMS Guidelines can I find this? This is going to dramatically change the way we do things, obviously, because like I said above, 99% of what I have found on the internet indicates the opposite (and yes, it is current info).

    Thanks for your help.

  6. #6
    Columbia, MO
    they are only symptoms if they are expressed by the patient as being the reason he is there. For the provider i=to inquire if the patient has had any of the following symptoms or issues is all history and not current symptoms, so it is still screening.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default
    Isn't there a modifier for screening turned diagnostic? Would that help?

  8. Default
    Yes it's the 33 modifier for comercial payors, however very few payors are currently recognizing this modifier. again secondary findings wether upon intake or during the proceedure do not change the patients reason and intent for the proceedure.Below I am attaching the current guideline we are following creating much happier patient's:

    Guidelines for When to Code for Screening and Diagnostic Colonoscopies in an ASC

    CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
    Differences in coding for screening or diagnostic colonoscopies have been a pressing issue for more than a decade. The new health reform law will make it all the more important.

    First, it is important to understand what a screening colonoscopy is. It is a procedure on a patient who has no symptoms (Non-therapeutic). This also involves patient histories such as personal or family history of polyps or cancer.
    By CPT guidelines enacted in 2010 by American Medical Association screening colonoscopies are performed on patients that have no presenting signs or symptoms related to the digestive system, but have reached the appropriate screening age. The ICD-9-CM diagnosis code V76.51( Special screening for Malignant neoplasm's, colon) is always the first Diagnosis code listed with any histories or findings listed secondary. In the case of a patient presenting for a non-therapeutic colonoscopy due to a heightened risk history the physician's documentation should reflect that the patient presented for a “screening colonoscopy in reference to the patient's specific history. The procedure should never be documented as “high risk surveillance” in reference to the specified history. This does not support the usage of the screening code which in turn will reduce the reimbursement from the insurance company and increase the patient liability unnecessarily.
    If a polyp or lesion is found and removed by snare during the screening colonoscopy, coding becomes more complicated. Now the procedure is billed as 45385 (colonoscopy with lesion removed by snare) and the selection of diagnosis code is a little more tricky.
    CMS requires the facility to bill for both the indication (screening) and the finding (polyp). On the HCFA 1500 form, you would enter V76.51 as the first diagnosis and 211.3 as the second diagnosis.

    Always use both diagnosis codes. Some payers still pay according to the intent of the procedure. That is, they will pay for a screening if that was what the patient came in for, even if a polyp is found. For this reason, it is vital to assign both diagnosis codes to the claim.

    Do not cite a symptom for a screening. If the procedure is a screening colonoscopy, the indication should not be a symptom. If the patient cites an additional symptom during scheduling or patient intake these diagnosis should be listed in addition to the presenting “screening” code as that was the primary intent for the procedure. Presenting diagnosis should never be replaced by additional findings. All findings should be reported from start to finish assuring accurate billing and reimbursement by the patient's insurance.

  9. #9
    We also have had many irate patients calling us stating that we coded the charge wrong per their insurance, etc, etc. We are still trying to figure out the best way to educate the providers and our patients on the intent of the procecure (screening vs. diagnostic). Would you be so kind to share the waiver you are now having your patients sign? How is everyone else dealing with these situations?

    Thank you!
    Christina Lee Wagner, CPC, CPC-H

  10. #10
    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.

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