# Payer guideline pole



## DEDGE CGIC (Aug 16, 2012)

Just trying to get a polling of opinions on the following subject:

The conflict is that different payers have different guide lines on personal histories being routine or non-routine. For example Anthem and CMS consider V12.72 as a high risk indicator for a routine screening indicating it should be billed out V76.51, V12.72.
However Cigna and United Healthcare specifically state a personal history is to be considered "diagnostic surveillance" and is not subject to the routine benefits. 

The question being posed is, if a coder is coding by CMS and CD-9 guidelines (V76.51, V12.72) Is it the provider's responsibility to omit the V76.51 code when billing payers that state there guidelines as non-screening for personal history or would it be the payer's responsibility to recognize the secondary diagnosis and apply patient liabilities based on their guidelines?

Thank you for your opinions.


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## pamsbill (Aug 20, 2012)

Can you please post links to the United Healthcare and Cigna policies you mentioned?  I am not aware of these policies and would like to see them.

Thank you,
PM


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## DEDGE CGIC (Aug 22, 2012)

http://www.cigna.com/assets/docs/he...s/807467_d_PreventiveHealthCovGuide_v8_HR.pdf

https://www.unitedhealthcareonline....ical Policies/Preventive_Care_Services_CD.pdf

http://www.aetna.com/cpb/medical/data/500_599/0516.html

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_c119565.htm

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/SE0613.pdf


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## pamsbill (Aug 23, 2012)

*Coachlang needed here!*

Argh. What a mess!

This affects the benefit coordinators too, since they give the indication for the procedure at the time of checking benefits.

This goes against everything we were posting before, about adding the V76.51ahead of the V12.72 because even if it is a high-risk screening, it is still a screening.  None of these payors are on the same page.  Do we have to look every time to see if a previous polyp was adenomatous before choosing  codes?  The problem is a high-risk screening has a different definition for every payor.

I think the only way to handle this is to make a chart detailing the definition of a screening for each separate payor.

Coachlang - chime in here!

Here is a brief summary:
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United Healthcare:
A patient had a polyp found and removed at a prior preventive screening colonoscopy. All future colonoscopies are considered diagnostic because the time intervals between future colonoscopies would be shortened.
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Cigna:

Colorectal cancer screening: beginning at age 50 by any of the following methods:
• Fecal occult blood testing (FOBT)/fecal immunochemical test (FIT), annually; or
• Sigmoidoscopy every five years; or
• Colonoscopy every 10 years; or
• Computed tomographic colonography1 (virtual colonoscopy) every five years; or
• Double contrast barium enema (DCBE) every five years

Covered for: V76.41, V76.50, V76.51, V76.52, V16.0, V18.51

Notice: NOT V12.72
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Anthem:
Has whole list of what is considered screening, prior non-adenomatous polyps is not on there so it falls under diagnostic??
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## coachlang3 (Aug 23, 2012)

Heh, what'd I do to get singled out on this?

*In my opinion* I think all the payors should follow CMS/Medicare's lead on screenings.  I think they just use personal history as a loophole so they don't have to pay and they can push the amount owed onto the patient.

I've heard the A/R people in my office explaining to patients that a "screening" is only a "screening" when the patient is asymptomatic and has no personal history and then it can only be done every 10 years.  So the other day I finally sat down with one of the reps and asked them about it.  She told me that is how the payors are explaining it to them.  They do not consider a screening (even a high risk screening) to be a true, preventative screening unless the pt is asymptomatic and has no personal history.  

It's really the whole Surveillance vs. Screening debate.  And I think it's a crock!!!!

If the patient isn't currently being treated for polyps, cancer, etc...., then it's a screening, period.  It's in the description HIGH RISK SCREENING!!!!!!!  Most payors accept the G codes (G0121 and G0105) so if they accept the G code for V12.72 and treat it as a screening why not accept the screening turned diagnostic code (45378,e tc...) with the V76.51 listed first.

Except for Medicare, since my regional accepts the history code as primary as long as we put the PT modifier on the claim, I put V76.51 as the primary dx on every charge that the documentation supports screening and then I put the findings and then I put the history code (family or personal).  

I don't know how the payors justify saying it's diagnostic when the patient has no symptoms.  The doctor's are screening a patient for colon cancer, they just happen to be doing it sooner because they are high risk based on a factor not on a symptom.

/rant off
/off soap box


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## bdobyns (Aug 23, 2012)

I have searched many articles and followed the discussions in the forum in the past. I will throw my 2 cents out there:

I think that these policies are really punishing the most at risk people of developing cancer.  Its very difficult to take preventive measure when your "life saving" procedure costs in excess of $1500 every 1-5 years.

Everywhere you look there is conflicting information (Which adds confusion):

Medicare considers personal history as high risk screening and their guidelines direct you to code the v76.51 and then the high risk indicator as the secondary diagnosis.  (V76.51, V12.72)

The AGA published an article in Jan 2011 stating that surveillance colonoscopies are high risk screening and direct you to code the high risk indicator to justify the frequency 1st followed by the V76.51 to indicate screening.  (V12.72, V76.51)

An Article by the AHIMA indicates to use the follow-up codes and then if a condition were to be found code the condition instead of the follow-up code I.E. (Indication V12.72, during the colonoscopy a polyp was removed, the diagnosis would only be 211.3) This same article tell you to look at official coding guidelines and payer policies for diagnostic colonoscopy performed following a history of previous polypectomy. (UHC CIGNA and many other carriers:  This is no longer considered screening).

Without any final ruling or direction that applies to all, my opinion is to code what the documentation supports.


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## coachlang3 (Aug 23, 2012)

bdobyns said:


> An Article by the AHIMA indicates to use the follow-up codes and then if a condition were to be found code the condition instead of the follow-up code I.E. (Indication V12.72, during the colonoscopy a polyp was removed, the diagnosis would only be 211.3) This same article tell you to look at official coding guidelines and payer policies for diagnostic colonoscopy performed following a history of previous polypectomy. (UHC CIGNA and many other carriers:  This is no longer considered screening).
> 
> Without any final ruling or direction that applies to all, my opinion is to code what the documentation supports.



I agree with everything you put on here except the above from AHIMA.  Unless the doctor specifically mentions "following up on a polyp removed X year/s ago" then it's not surveillance.  I'm also not saying you, just saying I don't agree with the AHIMA article you mentioned.  

The nationally recognized guidelines for average risk screening is 10 years and it's 5 years for high risk screening.  High risk screening is nationally recognized as anyone who has a personaly history of polyps or colorectal cancer or family history of the same.  It is still a screening as long as the patient is not being treated for the original polyp or cancer or symptoms related to the original polyp or cancer.  Usually the polyp has been removed so why on earth would a doctor be going back in 5 years later?  They would go back in within a year and then that would be surveillance and you would use a follow-up code.

These guidelines, which admittedly go back a few years, set back preventative medicine in every way possible just like *bdobyns* mentioned.  People won't go get checked until something bad happens and then it's too late and the bills go higher and the payors don't pay then either.  Not to get political but this is why a national initiative like "Obama/Romney care" is needed.  I may not like the whole thing as currently constituted but someone huge needs to take these payors to task and who's bigger than the federal government?


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## pamsbill (Aug 24, 2012)

Sorry Coach, I just know you are knowledgeable and were involved in some prior discussions about this very topic.  I agree with everything you wrote and I especially like your wording about explaining it to the patients:

_... a "screening" is only a "screening" when the patient is asymptomatic and has no personal history and then it can only be done every 10 years. _ 

I think I am going to recommend we do it this way and then, if an insurance does end up considering it a screening, it is a plus for the patient.  Otherwise it is as we explained to them in the beginning: it is not a screening because of your past history.

Now, how to get the insurance reps to STOP telling the patients we billed it wrong.
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The original question was do we treat the different payors differently?  For example, in Aetna's policy, it does not specifically state a prior history of polyps cannot be a screening, as it does in both United's and Cigna's policies.  So should we continue to use the V76.51 for these high-risk screenings?  I know for a fact the Aetna reps tell us to submit the claim using the V76.51 in the first position.  The dilemma becomes what Aetna is saying vs. what we are saying.  In the patient's eyes, we end up looking like we refuse to do what Aetna is requesting and the patients get angry with us.


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## coachlang3 (Aug 24, 2012)

I will continue to put the V76.51 as the first listed diagnosis and then the findings and then the personal history as long as the documentation supports it.  That way maybe it gets processed as a screening.  I know the payors are processing the claims the way they want to because I hear the conversations with patients that our A/R reps are having and it's seldom a good conversation.

To me the history (personal or family) is only relevent to the timing of the procedure not to the type of the procedure or why it was done (surveillance vs. screening).

History meansin the past not currently happening.


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## scorrado (Aug 24, 2012)

I know that I have voiced my opinion on this in the past and it has not been well received but I agree that personal history should be considered diagnostic based on the definition of history in icd-9. It states "Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment, but has the potential for recurrence, and therefore may require continued monitoring."  Sounds like a polyp falls under that category.  It no longer exists, it is not being treated, has the potential for recurrence, and requires continued monitoring.  If we follow the definitions we have been given - how can you code personal history as screening?


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## pamsbill (Aug 24, 2012)

Playing the devil's advocate here, my answer is because the patient is asymptomatic and, when the previous polyp was removed they were "cured" and no longer have the condition.  The only thing that changes is s/he has to come back more frequently because s/he may grow another one.  S/he is now at a higher risk for the condition but is not being actively treated for the condition and is not known to currently have the condition.  It is all semantics and it is how the insurers are getting out of following the new rules. (IMO)


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## scorrado (Aug 24, 2012)

The definition I gave you recognizes that the patient no longer has the condition and is no longer being treated. Obviously if you no longer have the condition you are asymptomatic.  V12.72 is the code that fits why the patient is having the colo - not V76.51 based on the defition we are given as coders.


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## coachlang3 (Aug 24, 2012)

Because they are not havng the procedure done because of the history.  They are having it done to "screen" for colorectal cancer.  They are having it done on a *shorter timeline* because they are at high risk based off of history not because of.

Now if the doctor wanted to see the patient for the polyps, ie surveillance, which is history of polyps, then you are correct.

That's why I said the documentation needs to be supportive of a screening.


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## scorrado (Aug 24, 2012)

I think we should all lobby for every insurances to follow the guidelines that Medicare has set up. I - like everybody else - get so tired of this game.  It is exhausting somedays!   I agree with you Coach but unfortunatly most op notes state the indication for procedure as history of colon polyps. To me that is V12.72.  All insurances need to get on the same page. Something as simple as a colonoscopy should not be this difficult.  Maybe the AAPC could involved and speak with some insurances and let them know that there needs to be some consistency in coding.


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## coachlang3 (Aug 24, 2012)

scorrado said:


> I think we should all lobby for every insurances to follow the guidelines that Medicare has set up. I - like everybody else - get so tired of this game.  It is exhausting somedays!   I agree with you Coach but unfortunatly most op notes state the indication for procedure as history of colon polyps. To me that is V12.72.  All insurances need to get on the same page. Something as simple as a colonoscopy should not be this difficult.  Maybe the AAPC could involved and speak with some insurances and let them know that there needs to be some consistency in coding.



BINGO---we have a winner here!!!

Susie, you just said it perfectly.  Payors should follow the Medicare guidelines which were taken from a government task force.  And also the statement you made about documentation!!!!


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## DEDGE CGIC (Aug 24, 2012)

*State and federal laws*

By the way, not to throw another wrench in the machine, but I thought this will help in the discussion. Per the Federal Affordable Care Act enacted in 2011.
10-16-104 Mandatory coverage provisions-definitions
Sub paragraph D subsection B

In addition to covered persons eligible for colorectal cancer screening coverage in a accordance with A or B recommendations of the task force, colorectal cancer screening coverage required by this subparagraph (V) shall also be provided to persons who are at high risk for colorectal cancer, including covered persons who have a family medical history of colon cancer; a prior occurrence of cancer or precursor neoplastic polyps; a prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, Chrohn's disease, or ulcerative colitis; or other predisposing factors as determined by the provider;

And since I'm in Colorado: Per the first regular session Sixty-seventh general assembly 
House bill 09-1204 
A bill for an act 
Concerning health insurance coverage for preventative health care services. 
Section 2. 10-16-104
Subsection (IV) Colorectal Cancer screening coverage
Sub-paragraph (B) Covered persons who are at high risk for colorectal cancer, including covered persons who have a family medical history of colorectal cancer; a prior occurrence of cancer or precursor neoplastic polyps; a prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, Chrohn's disease, or ulcerative colitis; or predisposing factors as determined by the provider;


I think this will insight some deep thought and hopefully more opinions on the matter. I guess the best question to pose to the payers is, Why does policy differ so much from law?


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## bdobyns (Aug 24, 2012)

The USPSTF recommendation statement for colorectal cancer screening has some interesting wording.  Under the Clinical Considerations section  "When the screening test results in diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable."


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## coachlang3 (Aug 27, 2012)

bdobyns said:


> The USPSTF recommendation statement for colorectal cancer screening has some interesting wording.  Under the Clinical Considerations section  "When the screening test results in diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable."



And this, folks, is why you double check a source you are paraphrasing from when you haven't read it in over a year, lol.

I thought the TF said the exact opposite.

Thanks for setting that record straight, bdobyns.


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## nsteinhauser (Aug 28, 2012)

But Coach - I'm still wanting to go with the Medicare guidelines (unless it's a payer that I know has different coverage policies).... 'screening' unless the patient has symptoms.... still a screening (albeit a 'high risk' screening) with personal hx polyps/CRC or fam hx of CRC.  Too bad the TF didn't get CMS to change their guidelines.


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## DEDGE CGIC (Aug 28, 2012)

*Uspstf?*

I'm confused as well USPSTF is written as a guideline of recommendations, with the original release date of 2008 and a vague update in 2012. I'm failing to see how their recommendation wording should have any effect on the federal & state (if applicable depending on the state) laws enacted after USPSTF's reported guidelines or the CMS and ICD-9-CM guidelines. 

Screening for Colorectal Cancer
Release Date: October 2008

The U.S. Preventive Services Task Force recommendation on Screening for Colorectal Cancer was published on October 7, 2008, by the Annals of Internal Medicine as an early online release. The print publication in Annals occurred on November 4, 2008. 	 

Chlamydial Infection: Screening (2007)
Cholesterol Abnormalities in Adults (Dyslipidemia, Lipid Disorders): Screening (2008)
Chronic Obstructive Pulmonary Disease: Screening (2008)
Colorectal Cancer: Screening (2008)
Coronary Heart Disease (Electrocardiography): Screening (2012)—New! 
Coronary Heart Disease (Risk Assessment, Nontraditional Risk Factors): Screening (2009)

Cancer Screening — United States, 2010
Weekly
January 27, 2012 / 61(03);41-45

Colorectal Cancer Screening 
The USPSTF guidelines call for regular screening of both men and women for colorectal cancer, starting at age 50 years and continuing until age 75 years, by any of the following three regimens: 1) annual high-sensitivity fecal occult blood testing, 2) sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years, or 3) screening colonoscopy at intervals of 10 years (2). Overall, 58.6% (CI = 57.3%–59.9%) of adults reported being up-to-date with colorectal cancer screening (Table 2). This is significantly lower than the Healthy People 2020 target of 70.5%. Nearly identical proportions of men (58.5%) and women (58.8%) reported being up-to-date. Whites were significantly more likely to report being up-to-date than blacks or Asians. Hispanics were less likely to report being up-to-date (46.5% [CI = 42.9%–50.2%]) than non-Hispanics. Among respondents who 1) had been in the United States for <10 years; 2) did not have a usual, nonemergency department source of care; or 3) did not have health insurance, less than a quarter reported having been screened within the recommended interval. Respondents aged 65–75 years were more likely to be up-to-date than those aged 50–64 years. Significant upward trends were seen in the proportion of adults up-to-date with colorectal cancer screening from 2000 to 2010 using any colorectal cancer screening regimen (Figure). 
Posting:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6103a1.htm


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## coachlang3 (Aug 28, 2012)

OK, I get the confusion on the part of the Gov't task force recommendations which were never enacted by the government but they have been followed by private payors.  Go figure

The rule of thumb that I have always gone by is: *Follow CMS guidelines unless the payor has specifically put in writing different rules.*

I agree with CMS's guidelines and I wholeheartedly think all payors should adopt these screening policies for many reasons.  Number one is more people would get screened and lives would be saved.  Number two it would clear up a lot of issues people have getting these claims paid.  Of course if they did what would I have to talk about!!!!


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## lisner1204 (Oct 25, 2012)

I realize this post was a couple months ago, but I am having this problem with a patient right now.  

I recently attended a GI seminar by a well known GI guru.  She stated the same thing *scorrado* posted.  

With the current patient, I may have billed it incorrectly though...She has a medicare replacement plan, personal history of polyps, no current symptoms, last screening was 5 years ago.  45378 v12.72 v76.51 was billed.  Should I have billed this as G0105-PT v76.51, v12.72?  This is a Humana Medicare Replacement and the original billing has caused the patient to incur a deductible.

Any thoughts?


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## scorrado (Oct 25, 2012)

I would have used the G0105 code for this one with V12.72 as the diagnosis.  I have had no issues not using the V76.51 with the high risk G code as far as payment.  Some people on here have, so you might have to contact the particular payor to ask them if just the V12.72 is sufficient for screening benefits or if they need the V76.51 also on the claim.  Hope this helps!


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## scorrado (Oct 25, 2012)

Oh I almsot forgot Lisner - someone actually agreed with me??? That doesn't happen very often - lol!  What seminar did you attend?  I would love to hear what the GI guru had to say on this hot topic. Any light that can be shed on this hot topic is helpful to me and others.


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