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Thread: colonoscopy coding

  1. #1

    Default colonoscopy coding

    AAPC: Back to School
    I know this is one of the most debatable issues in coding but I am going to ask...Is there a clear cut answer to if a patient has a history of colon polyps and is having a colonoscopy is it considered a screening? If there is an answer can someone tell me what reference they used to find it.

  2. #2
    Join Date
    Apr 2007



    At least one of the Medicare Carriers (Trailblazer - see above web link) has an LCD that shows V12.72 personal history of colon polyps is considered medical necessity for a diagnostic colonoscopy.

    Ingenix's EncoderPro coding software also shows V12.72 supports medical necessity for a diagnostic colonoscopy.

    Check with your area's Medicare Carrier and your commercial payors to see if they have the same policy.

    Hope this helps.

  3. #3
    Join Date
    Apr 2007
    Columbus GA

  4. #4
    Join Date
    Apr 2007



    CMS states that “A beneficiary is considered to be at high risk if he or she has any of the following risk factors…” and then listed is, “A personal history of adenomatous polyps.”

    This high risk screening is covered & represented by HCPCS G0105, “Colorectal cancer screening; colonoscopy on individual at high risk” (HCPCS Level II, AMA, 2011)

    So an answer to your question is YES, a history of colon polyps can be considered a screening…if they were adenomatous…and the insurance is Medicare or they accept the G codes.

    The reason this is a “debatable” issue is because some payers will consider the V12.72 as screening, but others as diagnostic. Unfortunately, there is no way to get around the private payers individual guidelines. UHC for instance specifically lists an example of diagnostic colonoscopy as “A patient had a polyp found and removed at a prior preventive screening colonoscopy. All future colonoscopies are considered diagnostic because the time intervals between future colonoscopies would be shortened.” (Preventive Care Services – Coverage Determination Guideline, UHC, 2010).

    BUT…I will also add that in their same policy…they indicate their “Claims Edit Criteria” as “G HCPCS codes are paid as preventive regardless of diagnosis.”

    There are many other different guidelines, frequency limitations, and coding criteria for the various payers. I have been gathering all of our payer information and reviewing all charges prior to billing to make sure the situation is coded correctly for the particular payer, as per their published policies.

    If you are unsure, I believe you could code the screening V76.51 first, and V12.72 secondary. If for some reason, they don’t accept this, or deny for frequency limitations, then it doesn’t seem inappropriate to rebill using just the V12.72 for reprocessing.

    I know this isn’t a clear cut answer you wanted…but unfortunately there is no clear cut answer…you will have to defer to the various payer policies and maybe test a few to make sure their claims systems are following the policies correctly.

  5. #5


    Also if the colonoscopy starts out as a screening and ends up being a diagnostic colonoscopy, you can put a modifier PT on the codes to show the initial intent of the procedure was for screening for colon cancer.
    ...I don't know if this is where the question was leading but thought it might be worthy to mention.

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