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Colon screening / history

  1. #11
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    Medical Coding Books
    Quote Originally Posted by coachlang3 View Post
    That's why you put the screening dx of V76.51 in the first slot to show the screening to the commercial carriers.
    I too would be interested in where it states this in the guidelines as I have found nothing that suggests what you are stating

    Debra A. Mitchell, MSPH, CPC-H

  2. #12
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    Debra,

    Are you asking me that?

    If so here it is:

    Also from pg 22 of the coding guidelines:

    "A screening code may be a first listed code if the reason for the visit is specifically the screening exam."

    So again, you can read this different ways too.

    How can you show the procedure was supposed to be a screening but converted to diagnostic with a V12.72 w/o using the V76.51? Sure, some payors will process correctly but not enough do.

    Also, on page 29 section IV, part A subsection 1 (outpatient surgery):
    "code the reason for the surgery as the first listed diagnosis"

    Well the reason for the surgery is screening colonoscopy. You cannot show that it is supposed to be a screening using 45378 (or other diagnostic codes) by using V12.72. That only states the pt has a history of polyps, it's a secondary dx to why the procedure is being done.

    Put it this way, a pt comes in for a screening and you use 45378 but they have no history, what dx would you use? V76.51 (which does not specify asymptomatic or otherwise, it only states Screening for malignant neoplasm, colon).

    Ok, now another pt comes in for a screening but has a history of polyps. 45378, V76.51 and V12.72.

    Once again for the first pt I would use G0121 and the V76.51.

    For the 2nd pt I wouls use G0105 and V12.72.

    But that's because the reason for the procedure is noted in the CPT itself for the G codes. It is not noted in the 45378 or diagnostic codes thereafter.

  3. #13
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    When a patient comes in for a colonoscopy for history of polyps that is the reason they are having the colonoscopy. They wouldn't be coming back after 2- 5 years if it was screening. They would be coming back in ten years. I think as stated previously - insurance companies just need to follow Medicare on this one. It would be so much easier!
    Susie Corrado, CPC
    __________________
    ENT Coding/Billing

  4. #14
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    What is a G0105? A high risk screening. And the timeline for that would be 2-5 years. It is still a screening. What makes it a high risk screening? The V12.72. It's still a screening.

    So I go back to the use of a diagnsotic CPT 45378. V12.72 can be used with 789.00 to show part of medical decision making but V76.51 cannot because then it wouldn't be a screening.

    V12.72 does not show anything about screening only that the pt has a history of something.

    The only way to show screening (w/o using the G codes that is) is to use a screening V code and those are V28 and then V73-V82 codes. Note that V12.72 does not fall under that category.

    I'm not saying you have to I'm saying you can and it does not break any coding law or ethic or moral and it shows the payor what was done and why it was done and lets them process the claim the correct way. The reason it was done with 2-5 years was a screening for malignant neoplasm with high risk indications. V76.51 (screening for malignant neoplasm) and V12.72 (hx of polyps, high risk indication).

    Tomato/tomahto-you choose I guess.

    But ask yourself, we use a PT modifier now for Medicare to show that it was indeed a screening converted even with the V76.51. And now the commercial payors are using (some) the 33 modifier to accurately show a screening.

    So why would they use those? (Other than the fact they want to create more stringent guidelines for pt's) So they can process the claims correctly because the V12.72 doesn't accurately tell them it's a screening to start with and we've all begged them to do it correctly.

  5. #15
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    Quote Originally Posted by coachlang3 View Post
    Debra,

    Are you asking me that?

    If so here it is:

    Also from pg 22 of the coding guidelines:

    "A screening code may be a first listed code if the reason for the visit is specifically the screening exam."

    So again, you can read this different ways too.
    How can you show the procedure was supposed to be a screening but converted to diagnostic with a V12.72 w/o using the V76.51? Sure, some payors will process correctly but not enough do.
    4
    Also, on page 29 section IV, part A subsection 1 (outpatient surgery):
    "code the reason for the surgery as the first listed diagnosis"

    Well the reason for the surgery is screening colonoscopy. You cannot show that it is supposed to be a screening using 45378 (or other diagnostic codes) by using V12.72. That only states the pt has a history of polyps, it's a secondary dx to why the procedure is being done.

    Put it this way, a pt comes in for a screening and you use 45378 but they have no history, what dx would you use? V76.51 (which does not specify asymptomatic or otherwise, it only states Screening for malignant neoplasm, colon).

    Ok, now another pt comes in for a screening but has a history of polyps. 45378, V76.51 and V12.72.

    Once again for the first pt I would use G0121 and the V76.51.

    For the 2nd pt I wouls use G0105 and V12.72.

    But that's because the reason for the procedure is noted in the CPT itself for the G codes. It is not noted in the 45378 or diagnostic codes thereafter.
    So sorry i used the wrong quote! I am in total agreement with you. I was wanting to ask the poster that stated the guidelines stated you cannot code personal hx and screening together to please show where that is stated. I read the same thingyou read andi apologize for the miss quote.

    Debra A. Mitchell, MSPH, CPC-H

  6. #16
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    No problem there. The way I put it, after I re-read, I wanted to ask myself where I got it, lol.

    The whole problem here is, really, semantics on our part but total confusion created by commercial payors.

    We see we can use V76.51 to show it was screening and that's ok. Should we be able to use V12.72? Yes. Medicare shows us we can. But they(commercial payors) won't process it as a screening thereby messing with the pt's benefits. Now, I won't change a code or do fraudulent billing, but if we can code it/bill it to show it was supposed to fall under the pt's screening benefits and the finding was due to the screening we should. It's not illegal, immoral or even unethical.

    I have had payors tell us and put it in writing via email that for them to process it as a screening or screening w/findings, ala Medicare, we have to put the V76.51 as the lead dx.

    It really is the commercial payors just trying to find any and every loophole so they don't have to pay.

    Maybe it's why I love Pixar's The Incredibles so much. Mr. Incredible really gives it to that loud mouthed, ignorant insurance fellow, lol.

  7. #17
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    Debra - in the coding guidelines in the front of the ICD-9 book under history is where I got my info regarding personal hx and family hx. It states family hx can be coded with screening and personal hx can be coded with followup. I guess the fact that the don't state that personal hx can be coded with screening is what bothers me but they definitely state that for family hx. Coach - I just watched the Incredibles the other night with my daughter for 100th time it seems - love that movie! You gave me a laugh this morning - Thanks!
    Susie Corrado, CPC
    __________________
    ENT Coding/Billing

  8. #18
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    Quote Originally Posted by scorrado View Post
    Debra - in the coding guidelines in the front of the ICD-9 book under history is where I got my info regarding personal hx and family hx. It states family hx can be coded with screening and personal hx can be coded with followup. I guess the fact that the don't state that personal hx can be coded with screening is what bothers me but they definitely state that for family hx. Coach - I just watched the Incredibles the other night with my daughter for 100th time it seems - love that movie! You gave me a laugh this morning - Thanks!
    But no where in the guidelines does it state that you can not code screening and person al history together. It is this very combination that indicates that a patient is at high risk and eligible for more frequent screening and it is not prohibited by guideline. Just because the guidelines do not indicated that a combination of codes can be used together does not automatically indicate that it is a prohibited combination. Therefore i respectfully disagree with your interpretation of the guidelines.

    Debra A. Mitchell, MSPH, CPC-H

  9. #19
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    Here's how I see it a little more cleanyl maybe:

    The reason the pt is having the procedure is for a screening.

    The reason the pt is having the screening at this time interval is because they have either a personal history or a family history.

    I was thinking about this overnight.

    Why would Medicare start using the PT modifier when they already process the claims as screening if you use either the V76.51, V12.72, V18.51, V10.05 or V16.0?

    Why would commercial payors start using the 33 modifier?

    Because they want to make sure they are processing the claims as screening under the pt's screening benefits.

    That means they are not processing them correctly if you use a diagnostic CPT. That's why UHC and the local BC have told us to use the V76.51 as the first diagnosis on our screening claims that convert. So they can process the claims according to the pt's screening benefits.

    Because V12.72 does not show it's a screening. But the 33 modifier will as does the PT modifier.

    But to another point now. With Medicare say you have a 45380, V76.51 and 211.3. Colon biopsy for an average risk screening with polyp findings. Why need the pt as you're already showing the screening? Because the PT modifier flips the switch on any procedure done that day.

    I just attended a gastro coding and billing seminar. What I didn't know was if you have a
    G0121 and a G0105 and say, a, 43239. You would put the PT modifier on the EGD CPT.

    What?????

    It's really only a switch for the Medicare computers to process the whole procedure visit under the screening benefit.

    Weird huh?

  10. #20
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    Interestingly, some commercial payers (specifically UHC) state in their guidelines for colonoscopy that if a patient has had a previous polyp removed it is no longer considered a 'routine screening' and therefore will apply to the patients medical benefits (deductible and co-insurance) because the patient is then recommended to have the colonoscopy at increased intervals.

    So, with UHC patients their insurance tells them that if they have a personal hx of polyps is ISN'T a routine screening. For these patients we code V12.72 as the primary diagnosis and don't add V76.51. When there is patient push back on this, I send them a copy of the UHC document that states the policy and then refer the patient back to the insurance to dispute it further.
    Elizabeth Escalante, CPC
    Operations Manager
    Atlanta Gastroenterology Associates

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