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Coding Colon Screenings for Commercial Payors

  1. #11
    Exam Training Packages
    I have read recently, and pardon me for not being able to quote the source, but findings other than polyps need not be reported with screenings.

  2. #12
    I have been told that once a patient presents with a history of colon polyps their colonoscopies can never be a screening again. Agree or disagree?

  3. #13
    Charlotte, NC

    Hence you have Medicare giving us the G0105 high risk screening code!!!

    Just because you have a history of something doesn't mean you are currently having issues from it that need to be treated.

    My opinion of course

  4. #14
    What about dx-ing that scenario?
    V7651 1st then V1272 if the scr is neg
    V7651 and 2113 if a polyp is found

  5. #15
    Charlotte, NC
    Actually Ocean,

    It would be, for Medicare,

    V12.72, 211.3 (if the pt had a hx of polyps that is) with a PT modifier.

    But for a commercial payor,

    V76.51, 211.3, V12.72 (technically you can use the 33 modifier, but like I've said commercial payors are denying our claims with that mod)

  6. #16
    I am currently in the midst of a test of Medicare and Commercial in Fla to find out excatly what you stated above.
    Last week I submitted about 400 claims to various carriers for an endo center in Fla with the history leading dx if present to see how they respond.
    This has been an ongoing debate in my office.
    I am of the mind that the hx not only identifies the procedure as a screening it also identifies (and should eliminate) frequency rejections.
    I am only coding the anesthesia portion of the service so I have no other way to impart high risk.

  7. #17
    Charlotte, NC
    Therein lies part of the problem. Proving high risk, especially for those under the age of 50, with out all the extra work to provide documentation.

    I would like to be able to follow Medicare's guidlines for the commercial payors but it just has never been feasible. The intent of the procedure/visit is to screen for malignant neoplasms (ie colon cancer). Hence the fact they had any history whatsoever (family or personal) makes no difference as long as they are not currently being treated for that history. High risk is just an indicator for frequency or for age (ie 25y/o w/pers hx of polyps). Most payors don't like the G codes so you must use the diagnostic 45378 (or appropriate CPT). Now if you then code a V12.72 or V16.0 along with the 45378, the payor will generally see that as diagnostic instead of screening and will process it as such thereby skipping over the pt's screening benefits. Is that fair to the pt? To the billing physician who then has to make calls and use time to contact the payor to correct the error? It also withholds timely payment to the doctor and staff.

    UHC and BCBS have both told the practice I work for to put the V76.51 as the first dx and then put findings and then history. That is so they see the screening and process it accordingly. It says to me they are too lazy to actually care and see all the dx's.

    The whole problem was fixed by the creation of the 33 modifier but as I've said previously, every single claim we sent in, to every commercial payor, with the 33, was denied.

    I'd be interested to see your test findings though.

  8. Default
    In response to rcclary's post (above) - ever since the Affordable Care Act was passed, mandating coverage of 'screenings' without coinsurance or deductible, commercial payers have been changing their policies/benefits to limit the number of "screenings" they will have to cover - in case the Act doesn't get repealed.

    Regarding colorectal cancer screenings, we're starting to see policies from commercial payers that specifically state that if a 'member' has a personal history of colon/rectal polyps, their colonoscopy is not considered a screening. (Scary...pretty soon you won't be able to get any preventive services unless you've never been to a doctor before.) So rcclary - you may have been looking at coverage and benefits from a commercial policy.

    Medicare considers it a screening (high risk) if the patient has a personal history of polyps but the commercial payers are trying to shrink the number of procedures that they pay for under their 'screening' benefits.

    Coach - I'm with you - I wish everyone was on the 'Medicare' page as far as coding for colonoscopies. It's easier when there's just one set of rules to follow.

  9. #19
    Thanks Debra, that reply has really helped me!

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