# Patient furious about screening turned diagnostic colonoscopy



## trinalankford

We have a patient who came in for a 10-year followup colonoscopy (personal history of colon polyps). However, in the MD visit right before the procedure, he made mention of several (MANY) symptoms he had been having, all relating to GI tract.

I am under the impression that at the point he shared his first symptom, this is no longer a "screening" colonoscopy and instead turned diagnostic. It was billed as such (diagnostic), and surprise surprise, the insurance applied to deductible rather than paid at 100% (which it would have a screening).

Our patient is livid. He stated that he would not have had the test done for his symptoms and only mentioned the symptoms because "the doctor asked." I explained that because they were documented, that is what I have to code and thus bill by.

We have actually changed our office policy because of this patient. We now have colonoscopy patients sign a waiver, stating the difference between a diagnostic and a screening colonoscopy, but we are still dealing with the backlash of this one.

Can someone verify, please, that it was coded/billed correctly as a diagnostic rather than screening as a followup of colon polyps?

Thank you.


----------



## mitchellde

If the patient related that these these had been symptoms but that he was here for a screening and not currently complaining of anything then it should have been a screening.  Having had a symptom and affiming this in response to a question does not make this a reason for an exam.


----------



## trinalankford

Even if by looking at the op note (only thing the hospital had to bill by), there is NO MENTION made of screening, only all of these symptoms?

Yes, I am billing for physician not hospital, but I am curious now.


----------



## DEDGE CGIC

The patient schedule is part of the patient's Medical record and if a non-Theraputic Routine colonoscopy was what he scheduled for it should be the primary Dx despite additional claims or findings. your best option now is to ask your physician to amind the medical record with the original reason being added as the primary presenting Dx and file a corrected claim with the insurance. By 2010 CMS guide lines all non-theraputic colonoscopies should be billed routine with histories and findings to follow. Hope this helps


----------



## trinalankford

Everything I have found (prior to this) is indicating just the opposite. I have pages and pages printed from the internet (this site, Medicare site, and others) that say it cannot be a screening if symptoms are listed.

Where in the 2010 CMS Guidelines can I find this? This is going to dramatically change the way we do things, obviously, because like I said above, 99% of what I have found on the internet indicates the opposite (and yes, it is current info).

Thanks for your help.


----------



## mitchellde

they are only symptoms if they are expressed by the patient as being the reason he is there.  For the provider i=to inquire if the patient has had any of the following symptoms or issues is all history and not current symptoms, so it is still screening.


----------



## Kelly_Mayumi

Isn't there a modifier for screening turned diagnostic?  Would that help?


----------



## DEDGE CGIC

Yes it's the 33 modifier for comercial payors, however very few payors are currently recognizing this modifier. again secondary findings wether upon intake or during the proceedure do not change the patients reason and intent for the proceedure.Below I am attaching the current guideline we are following creating much happier patient's:



Guidelines for When to Code for Screening and Diagnostic Colonoscopies in an ASC

CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
.
Differences in coding for screening or diagnostic colonoscopies have been a pressing issue for more than a decade. The new health reform law will make it all the more important. 

First, it is important to understand what a screening colonoscopy is. It is a procedure on a patient who has no symptoms (Non-therapeutic). This also involves patient histories such as personal or family history of polyps or cancer. 
By CPT guidelines enacted in 2010 by American Medical Association screening colonoscopies are performed on patients that have no presenting signs or symptoms related to the digestive system, but have reached the appropriate screening age. The ICD-9-CM diagnosis code V76.51( Special screening for Malignant neoplasm's, colon) is always the first Diagnosis code listed with any histories or findings listed secondary. In the case of a patient presenting for a non-therapeutic colonoscopy due to a heightened risk history the physician's documentation should reflect that the patient presented for a “screening colonoscopy in reference to the patient's specific history. The procedure should never be documented as “high risk surveillance” in reference to the specified history. This does not support the usage  of the screening code which in turn will reduce the reimbursement from the insurance company and increase the patient liability unnecessarily. 
If a polyp or lesion is found and removed by snare during the screening colonoscopy, coding becomes more complicated. Now the procedure is billed as 45385 (colonoscopy with lesion removed by snare) and the selection of diagnosis code is a little more tricky.
CMS requires the facility to bill for both the indication (screening) and the finding (polyp). On the HCFA 1500 form, you would enter V76.51 as the first diagnosis and 211.3 as the second diagnosis. 

Always use both diagnosis codes. Some payers still pay according to the intent of the procedure. That is, they will pay for a screening if that was what the patient came in for, even if a polyp is found. For this reason, it is vital to assign both diagnosis codes to the claim.

Do not cite a symptom for a screening. If the procedure is a screening colonoscopy, the indication should not be a symptom. If the patient cites an additional symptom during scheduling or patient intake these diagnosis should be listed in addition to the presenting “screening” code as that was the primary intent for the procedure. Presenting diagnosis should never be replaced by additional findings. All findings should be reported from start to finish assuring accurate billing and reimbursement by the patient's insurance.


----------



## cedwards

We also have had many irate patients calling us stating that we coded the charge wrong per their insurance, etc, etc.  We are still trying to figure out the best way to educate the providers and our patients on the intent of the procecure (screening vs. diagnostic).  Would you be so kind to share the waiver you are now having your patients sign?  How is everyone else dealing with these situations?

Thank you!


----------



## KBOVA

I do not agree with those that would indicate a screening dx can primary when the patient has active GI s/s that would prompt the doc to do a colonoscopy to investigate.  The screening portion of the ICD9 book makes it very clear that screening can only be the primary dx in in patients without presenting s/s.


----------



## mitchellde

KBOVA said:


> I do not agree with those that would indicate a screening dx can primary when the patient has active GI s/s that would prompt the doc to do a colonoscopy to investigate.  The screening portion of the ICD9 book makes it very clear that screening can only be the primary dx in in patients without presenting s/s.



My point is.. and I have seen this happen.... The patient arrives for their colonoscopy which they have scheduled as a screening per prompting from their physician, the Doctor now asks the patient about prior symptoms, " have you experienced any...., have you had any instances of....."  and the patient answers honestly that yest this, and that have existed... these are not presenting symptoms, and do not change the exam from a screeing.  The patient has answered specific questions in an honest and direct fashion without indicating that this is why they wish to have a diagnostic study.  The patient gets to control this and they have requested a screening.  If the physician feels a diagnostic study is in order then the patient needs to be informed of this so that they may think it over and agree.  When you wrote the permit for the study did you indicate that the patient was consenting to a screening colonoscopy or a diagnostic?  Your permit must be specific if it is generic, patient consents to colonoscopy, then the patient decision that this was screening stands.


----------



## trinalankford

mitchellde said:


> My point is.. and I have seen this happen.... The patient arrives for their colonoscopy which they have scheduled as a screening per prompting from their physician, the Doctor now asks the patient about prior symptoms, " have you experienced any...., have you had any instances of....."  and the patient answers honestly that yest this, and that have existed... these are not presenting symptoms, and do not change the exam from a screeing.  The patient has answered specific questions in an honest and direct fashion without indicating that this is why they wish to have a diagnostic study.  The patient gets to control this and they have requested a screening..



...And this is exactly what is happening in my doc's case. He wouldn't be doing his job if he didn't quiz the patient right before the procedure as to why that patient is there for the procedure, especially in the cases where that patient has NOT seen the doc yet.



mitchellde said:


> When you wrote the permit for the study did you indicate that the patient was consenting to a screening colonoscopy or a diagnostic?  Your permit must be specific if it is generic, patient consents to colonoscopy, then the patient decision that this was screening stands.



It states that the patient understands that what is starting out as screening may end up as diagnostic (polyp, bleeding AVM, etc.), and thus may change what/how the insurance is paying. We implemented this permit BECAUSE of the patient mentioned above.

...And this whole thread? You can see why there is contradictory information out there...there is contradictory information in this thread itself. Unfortunately, when doing a google search, it is contradictory, also.

Thanks to those who have tried to help.


----------



## ollielooya

I have been watching this thread with extreme interest and it appears there is no absolute determination, or is there?  Depending on who would "audit" this scenario there is a possibility either could be correct?  Ultimately, who or what would be the final authority?   Anything in the works from AMA or MCR to help resolve such cases?  Just a thought-- perhaps a lawyer is needed for interpretation?  

Glad this thread was posted..

---Suzanne E. Byrum CPC


----------



## mitchellde

trinacmt said:


> ...And this is exactly what is happening in my doc's case. He wouldn't be doing his job if he didn't quiz the patient right before the procedure as to why that patient is there for the procedure, especially in the cases where that patient has NOT seen the doc yet.
> 
> 
> 
> It states that the patient understands that what is starting out as screening may end up as diagnostic (polyp, bleeding AVM, etc.), and thus may change what/how the insurance is paying. We implemented this permit BECAUSE of the patient mentioned above.
> 
> ...And this whole thread? You can see why there is contradictory information out there...there is contradictory information in this thread itself. Unfortunately, when doing a google search, it is contradictory, also.
> 
> Thanks to those who have tried to help.



Yes you are tell the patient this procedure will START OUT AS SCREENING but MAY become diagnostic if there are findings.  What you then did was indicate the procedure was never screening and started out as diagnostic due to presenting symptoms, which as I am understanding is not true.  The patient was asymptomatic on presentation and merely indicated symptoms had been present in the past.  This is clearly screening and should be listed with the V code for screening first.  The 33 modifier (PT for Medicare) will then be used if a diagnostic procedure had to be performed due to findings.


----------



## SDIGANGI

We just went through this in our office and we found in the "medical practice coding pro" and verified this on the medicare site in their policy manual the following:

This was the question posted: 

"frequently, the primary care physician will refer patients for "colonoscopy screening" when in fact the patient is having gi symptoms that mean the patient should have a diagnostic colonoscopy instead. After the patient comes in for an office visit with our gi doctor and the colonoscopy is scheduled, can the colonoscopy be billed as diagnostic even though the pcp ordered a "screening"?"

this was the answer posted:

" the medicare benefit policy manual states that when an interpreting physician determines an ordered test is clinically inappropriate or suboptimal, and a different test should be performed, " the interpreting physician/testing facility may not perform the unordered test until a new order form the treating physician/provider has been retrieved". In other words, the gi doctor can contact the ordering physician and explain why a diagnostic study is more appropriate.....unless the gastro asks the original physician to change the order for the test, you are really stuck doing the screening requested, according to medicare policy."

after much searching, i did verify this with the medicare policy to be correct.  If a patient is referred for a screening and they state symptoms, you can see them and treat for the symptoms but the colonoscopy has to be billed as a screening primary and any diagnostic findings secondary.


----------



## nc_coder

I used to work for a General Surgeon.  We had this problem with patients all the time.  They would go in for a screening.  If the surgeon found a polyp and removed it, the procedure would turn diagnostic.  I had many patients say they went in for a screening and that was what they consented to.  I always had to explain that the physician would not just leave a possibly cancerous polyp while doing the scope.


----------



## mitchellde

nc_coder said:


> I used to work for a General Surgeon.  We had this problem with patients all the time.  They would go in for a screening.  If the surgeon found a polyp and removed it, the procedure would turn diagnostic.  I had many patients say they went in for a screening and that was what they consented to.  I always had to explain that the physician would not just leave a possibly cancerous polyp while doing the scope.



Yes but this is different, this was a screening that became diagnostic and the operative permit must have contained a phrase for this this such as consent for screening colonoscopy with possible biopsy or polypectomy as necessary.  If this is not there then you cannot perform the diagnostic portion, also the screen V code is still the first listed code with the findings secondary.  The original poster though is a bit different scenario, this patient arrived for a screening filled a permit out for screening and then was coded as though it were a diagnostic exam based on the answers to questions regarding the past presence of symptoms.  This cannot be done, it is always screening first listed with finding secondary, when the patient is requesting a screening test.


----------



## gastro59

*Its a screening*

This is a screening no matter what- if it was ordered as a screening then it is a screening,
go by the referring physician's order, pts. will elaborate on GI symptoms but the referring 
physician is the one ordering the procedure and he ultimately wanted a screening 
done..
Linda L. Jackson, CPC-CGIC


----------



## dadhich.girish

I agree with it being screening.  The intent is what decides the procedure.  Here the intent is screening and so should be the code.


----------



## acbarnes

Wow! Good to know we are not the only practice whose patients scream. 

If we can't agree in this forum, how do we can expect patients to understand. PCPs do not get it either. They will send a patient for Screening (V76.51) when in fact the patient is Surveillance (Personal Hx Polyps, V12.72). Screening and Surveillance are not the same thing. For example, UHC defines a patient with a personal history of polyps as surveillance due to the increased frequency of colonoscopy and not covered under the Affordable Care Act Colon Screening benefit. This type of colonoscopy is covered under their regular benefits, not 100% screening. Many insurance companies have caught on and are now adding these medical policies. This means that for many companies only patients 50+ with no history, no symptoms, and no grandfathered health plan will receive a 100% paid colonoscopy. 

To help solve this issue, we have patients read and sign a colonoscopy waiver before check in and a Colon Notification Form with their anticiapted CPT/Dx codes informing them to call their ins companies to determine their benefits. They are on our website under patient forms, www.atlantacolon.com. It has reduced our billing calls by at least 50%. 

Anna Barnes, CPC, CEMC, CGSCS


----------



## scorrado

Great forms Anna!  I am going to print a couple of them and show my manager.  Thanks for sharing.


----------



## nsteinhauser

It's good to read everyones thoughts about this; hours are spent dealing with these issues with patients, surgeons and payers.  Can anyone tell me where to find (from CMS or the AMA) documentation that delineates their guidelines for "screeening" versus "surveillance" colonoscopies, if they have any such documentation?  CMS in the past still used the "screening" codes ("G" codes) for both but split it into no-risk screening (for no history) and high-risk screening (for personal history of polyps of fam hx of colon cancer).

There is a lot of information available relating to 'screening' versus 'diagnostic or therapeutic' but  is their anything specifically addressing "screening' versus 'surveillance'? 

Thank you for the help.


----------



## acbarnes

I guess I should have clarified about the screening versus surveillance. 

This was in reference to some recent 3rd party insurance company medical policies and the physician medical language; not Medicare and Medicaid. To my knowledge Medicare does not recognize the difference in writing. You are correct in that Medicare uses the "G" codes to differinate between high risk (G0105) and average risk (G0121). the Medicare Colon Screening policy can be found at http://www.cms.gov/ColorectalCancerScreening/   and the policy manual at http://www.cms.gov/manuals/downloads/clm104c18.pdf. As you know, what CMS sets as standard does not always follow for the 3rd party carriers. 

Anna Barnes, CPC, CEMC, CGSCS


----------



## rhaney88

I think if the pt was there for a recall LE I would have billed the screening code. Our doctors often have the pts state at time of the colonoscopy that they are having this problem or that problem but if you recalled the pt for a screening and there was no office visit documenting/diagnosing the problems it should have remained a screening.


----------

