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Gastroenterology Coding Alert

Coding Medicare Screening Services? Don't Forget V Codes

Published on Wed Sep 08, 2004

Code makes colorectal cancer screening claims rock-solid

If you aren't reporting V codes on claims to Medicare for colorectal cancer screening services, your office could face denials due to lack of medical necessity, experts say.
 
Why? The coder must "assign the most precise diagnosis codes [to reflect] the physician's narrative description of the symptom or diagnosis," says JoAnn Baker, CCS, CPC-H, CPC, CHCC, an education specialist in East Orange, N.J. In many cases, that precision requires V codes because they often identify reasons for medical encounters for other than disease or injury.

Gain Reimbursement Victory With Help of V Codes

"Let's face it, in addition to reflecting utilization patterns and appropriateness of healthcare costs, V codes do impact payment" for some gastro services, says John F. Burns, CPC, president of Modern Conventions in Compliance Inc., in New York. "In other words, if you don't use them, you won't get paid."
 
Finding the right V code for colorectal screening procedures takes only a little more effort for the coder - and goes a long way toward keeping your office in compliance with insurers.

High-Risk Screenings Should Always Have V Code

For a high-risk patient older than 50, Medicare will pay for a colorectal cancer screening once every two years, but to identify a patient as high-risk, you must include a V code on the claim, Burns says.
 
Coding truth: If the gastroenterologist performs a colorectal cancer screening on a 50-year-old high-risk Medicare patient, Burns recommends:
 

  • reporting G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for the high-risk cancer screening.
     
  • linking the appropriate V code to G0105. Some V codes that prove medical necessity for G0105 are V10.05 (Personal history of malignant neoplasm; large intestine), V10.06 (... rectum, rectosigmoid junction, and anus), and V16.0 (Family history of malignant neoplasm; gastrointestinal tract).
     
    Coding consequences: "If the V code for personal or family history is not reported, [Medicare] will deny the G0105 claim," Burns says. Include a V code on every colorectal cancer screening for high-risk Medicare patients.

    V Codes Are a Must For Prescreening E/Ms

    V codes should also be used when the gastroenterologist provides a pre-colonoscopy screening for an asymptomatic Medicare patient. Gastros commonly perform this screening before an average-risk colorectal cancer screening (G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).
     
    Example: Let's say a new Medicare patient calls and wants a colorectal cancer screening. The patient is not high risk, but before scheduling the colonoscopy the gastroenterologist still examines the patient for risk factors that may endanger him during the screening. The patient has no such factors, so the gastro approves the patient for the procedure.
     
    This type of visit is typically a level-one service. If your office reports an E/M code for this procedure, you
    should report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making) with V72.83 (Other specified preoperative examination) and V76.51 (Special screening for malignant neoplasms; colon) attached.
     
    Why? The V codes prove to Medicare that the doctor performed the E/M service to ensure patient safety before a colorectal cancer screening on a new patient.
     
    Note: CMS has said that the pre-op E/M is "medically necessary" to rule out any underlying medical conditions that could put the patient in jeopardy during a surgical procedure. 
     
    Unfortunately, national policy about the colorectal screening benefit also stipulates that Medicare does not cover an E/M service for an asymptomatic patient prior to a screening colonoscopy.
     
    This means that Medicare will not pay for 99201 for an average-risk patient. You can bill the patient, however, if you obtain an advance beneficiary notice before the service.

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