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Consult and colonoscopy

  1. #11
    Location
    Swainsboro/Statesboro, GA
    Posts
    753
    Default OV's (prior to or after) screening colonoscopies
    Exam Training Packages
    Hello all,

    First let me say I have read through several threads and have learned a lot about this subject. That being said, let me also say that I have not worked in GI in over ten years. So here is my situation/question:

    While talking with a GI physician, I was shocked to learn that no OV is charged when the patient is referred to the GI office for a screening colonoscopy. The physician explained that Medicare, and now other insurance companies, will not cover a consult or other OV when the visit is the visit prior to the screening colonoscopy. There is no diagnosis or symptoms other than "screening colonoscopy".

    I have been researching and looking for regulations to support this. I have read both links posted in this thread from Jenny and F Tessa (thank you both VERY much for the links) and everything else I can find relating to this subject.

    So finally, here are my questions!

    In what situations can a consult or OV be charged when the patient is coming for the visit prior to scheduling a screening colonoscopy? (Let's assume this is a new patient).

    Could this visit be considered a surgical clearance and be submitted with dx code V72.83?

    Isn't it "reasonable and necessary" for this patient to be examined by the GI physician prior to performing a procedure where sedation is involved?

    Since there is no reimbursement difference between a screening colonoscopy and a diagnostic colonoscopy, why shouldn't the physician be compensated for the work performed during that pre-procedure visit?

    If the pre-procedure visit really is not billable, and the procedure itself is normal, wouldn't that make any post-procedure visit unbillable also?

    Does anyone bill the patient for the pre-procedure visit?

    Does anyone have the patient sign an ABN?

    And just to clarify, "pre-procedure visit" means on a different date from the screening procedure.

    I appreciate any thoughts and opinions on this subject.

    Thanks so much.
    Freda
    Savannah, GA

  2. #12
    Location
    Milwaukee WI
    Posts
    4,466
    Default Eval is part of RVU for procedure
    Freda,
    You ask a lot of good questions, but I'm only going to address one in this response.

    I hear over and over again from a variety of different specialties ... "why can't I get paid for the work of the eval?"

    The answer is that the "surgeon" IS being paid for the work of the eval prior to a procedure. The RVUs (and the reimbursement) for the procedure INCLUDE this type of necessary eval prior to any procedure.

    That being said, I do think it is appropriate to capture some evaluation service for the new patient who has never been seen in your office before (99201-99205 as per medical necessity and documentation). In the case where this visit occurs days or weeks before the scheduled procedure date, you don't even need a -25 modifier.

    I hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #13
    Default
    We have been billing new patient visits to Medicare without an ABN with dx: v76.51/v76.41. The eob states that it is the patient's responsibility. Are we required to have the patient fill out an ABN for these visits? I had one patient try to appeal with Medicare and their finding was that the patient was responsible for the bill. Is Medicare assuming we have an ANB on file?

    They EOBs also don't reduce the amount by the Medicare allowable, but don't we have to reduce it to be compliant?
    Last edited by Jarts; 03-30-2009 at 12:04 PM.

  4. #14
    Location
    Swainsboro/Statesboro, GA
    Posts
    753
    Default ABN for the visit
    My understanding of ABNs is that if the service is never covered, an ABN is not needed. If, however, the service is usually covered but you have reason to believe it may not be covered, you would want to get an ABN.

    In the situations we have been discussing in this thread, I would want an ABN for the visit because a visit is usually a covered service.

    I do not believe a provider is required to make an adjustment on a noncovered service. But that does bring up the whole issue of transparent pricing!

    On the subject of the global surgical package, I completely agree with and understand that concept, but don't most surgeons charge for their visit to determine the need for the surgery, even if the patient is referred/sent by their PCP for a specific surgery visit? There is no reimbursement difference (on the MPFS) between a high risk screening colonoscopy, a non-high risk screening colnoscopy and a diagnostic colonoscopy. It just seems like the GI physicians are out that visit reimbursement when screening is the only reason for the visit.

    I really think the whole issue with the screening colonoscopy is that there is no diagnosis code for that office visit except the screening code. I also heard that a Carrier had stated if physicians grab any complaint and use that as the diagnosis for these visits, they would be in trouble. I haven't been able to confirm this, so if anyone has any info, please share!

    Thanks so much!

  5. #15
    Default
    Quote Originally Posted by fredabrinson View Post
    My understanding of ABNs is that if the service is never covered, an ABN is not needed. If, however, the service is usually covered but you have reason to believe it may not be covered, you would want to get an ABN.

    In the situations we have been discussing in this thread, I would want an ABN for the visit because a visit is usually a covered service.

    I do not believe a provider is required to make an adjustment on a noncovered service. But that does bring up the whole issue of transparent pricing!

    On the subject of the global surgical package, I completely agree with and understand that concept, but don't most surgeons charge for their visit to determine the need for the surgery, even if the patient is referred/sent by their PCP for a specific surgery visit? There is no reimbursement difference (on the MPFS) between a high risk screening colonoscopy, a non-high risk screening colnoscopy and a diagnostic colonoscopy. It just seems like the GI physicians are out that visit reimbursement when screening is the only reason for the visit.

    I really think the whole issue with the screening colonoscopy is that there is no diagnosis code for that office visit except the screening code. I also heard that a Carrier had stated if physicians grab any complaint and use that as the diagnosis for these visits, they would be in trouble. I haven't been able to confirm this, so if anyone has any info, please share!

    Thanks so much!
    thanks for responding to my portion of this thread

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