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Medicare colon screening with polypectomy

  1. Angry Medicare colon screening with polypectomy
    Medical Coding Books
    I have this problem time and time again, colonoscopies should be so easy to code...........every insurance wants it done a different way. Why can't insurance companies all get on the same page here??????

    Medicare patient comes into an ASC for a screening colonoscopy. Two polyps found, one removed by snare in colon, one biopsied from rectum.

    I coded as primary dx v76.51, 211.3, 211.4
    CPT 45385, 45380 mod 59

    Medicare pays claim except for 20%. Submitted to PA BS who does not cover screening colonoscopies. Patient gets a bill and is not happy.

    To top it all off, dr's office is paid in full because they did not bill the v76.51 as primary. (which I thought you have to do since Medicare is primary and that is what/how they want it coded). So patient wants me to resubmit it without v76.51...............

    I am so ready to pull my hair out and I really need some help from my coding world friends. Please help to clarify my way of thinking.

  2. #2
    Greeley, Colorado
    Kelly - I code for both the physician and the ASC. When listing the diagnosis codes on the claim (box 21/edi equivalant? - I don't have a form in front of me) = 1. V76.51 2. 211.3 3. 211.4; link only the polyp codes to the CPT's. This indicates that the initial intent was screening but polyps encountered and biopsied/removed. That's the way Medicare wants it...and the secondary should be ok with this coding. Are you actually linking V76.51 to the CPT's?
    Lisa Bledsoe, CPC, CPMA

  3. Default
    According to our billing company, our software does not have the ability to use dx pointers. ?????

  4. Default
    Do you have the ability to print the claim yourself? What I used to do when I was working with a program that would not allow me to link particular dx was to print the claim, then white-out the dx pointer for the V76.51 dx, leaving only the medical dx linked to the procedure. A lot of trouble, I know.

    I agree with you that colonoscopies should be fairly straightforward to code and bill. Unfortunately, they are not, mostly due to carriers' payment policies. And patients don't understand why you can't just change the coding so they won't have to pay anything when it goes against their deductible. Sometimes the carrier will even tell the patient that the provider "coded it wrong" and that is the reason they are having to pay.

  5. #5
    Greeley, Colorado
    Quote Originally Posted by Ksumansky View Post
    According to our billing company, our software does not have the ability to use dx pointers. ?????
    Then your billing company needs to contact the software vendor and they need to fix this. You should be able to link your dx codes appropriately. We had a similar issue with our practice management system and they had to write a "fix" for the issue.
    Lisa Bledsoe, CPC, CPMA

  6. Default
    Thank you both! I will talk to our billing company and see what can be done.

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