Gastroenterology Coding Alert

As Medicares colorectal screening benefits become more widely publicized, primary care physicians (PCPs) are referring an increasing number of patients to gastroenterologists for high-risk screening colonoscopies. If the patient has a chronic gastrointestinal disease, however, the gastroenterologist may be able to report a diagnostic colonoscopy instead of a high-risk screening and bill an evaluation and management (E/M) service along with the encounter. Some local carriers are beginning to require that a follow-up colonoscopy performed on a patient who has a personal history of polyps and no additional gastrointestinal symptoms be reported as a high-risk screening procedure instead of a diagnostic one.

Screening Colonoscopies for Those at Risk

Medicares national policy on colorectal screening, which was passed as part of the Balanced Budget Act of 1998, stipulates that screening colonoscopies are covered once every 24 months for beneficiaries at high risk for colorectal cancer. Unlike the other colorectal screening benefits, there is no minimum age requirement.

Medicares national policy defines high risk for colorectal cancer as an individual with one or more of the following:

Close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyposis;

Family history of familial adenomatous polyposis;

Family history of hereditary nonpolyposis colorectal cancer;

Personal history of colorectal cancer; or

Inflammatory bowel disease, including Crohns disease and ulcerative colitis.

The designation of specific ICD-9 codes that should be used to establish the beneficiarys high-risk status has been left to the individual carriers and varies significantly from state to state. (For more on these codes, see Choosing Correct ICD-9 Codes for Colorectal Cancer Screenings on page 5 of the January 2000 Gastroenterology Coding Alert.)

Medicare Requires G0105 for High-risk Screening

Medicare requires HCPCS code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) when reporting screening colonoscopies performed on asymptomatic patients at high risk. Use 45378 (colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) to report diagnostic colonoscopies performed on patients exhibiting signs and symptoms of gastrointestinal disease.

If, during the course of a high-risk screening colonoscopy, the gastroenterologist finds a polyp, lesion or other growth, the appropriate diagnostic colonoscopy procedure code (45378-45385) should be billed instead of G0105.

Determine Whether Patients Qualify

Although Medicares national policy seems quite detailed, physicians are still unclear about what is covered. The high-risk screening benefit is one of the hardest policies to interpret, says Christine Martin, CPC, practice manager at Commonwealth Gastroenterology Associates, a three-physician practice in Lexington, Ky.

Because this Medicare policy is relatively new, many primary care physicians often are confused about what it covers, says Martin, who adds that most of her practices screening patients are referred by their PCP. Some primary care physicians, for example, look at the number of relatives as well as the closeness of the relationship when determining whether a patient is at high risk due to a family history of colon cancer. As a result, a physician might consider having a grandparent and two aunts with colon cancer to put someone at high risk, but Medicare only covers mother, father, sister, brother and child.

To make sure that the patient qualifies under Medicares specific policy for a high-risk screening colonoscopy, appointment schedulers at Martins office will ask questions about the patient when the PCPs office arranges the appointment. The questions also help the scheduler determine whether the patient has any signs or symptoms that would qualify him or her for a diagnostic colonoscopy, and when his or her last high-risk screening colonoscopy was performed.

Usually its a staff person, not a physician or nurse, who calls to arrange the colonoscopy, and that person may not know the difference between a high-risk screening and a diagnostic procedure, explains Martin. So we ask if the patient is experiencing symptoms to determine whether this is really a diagnostic procedure. Because we tend to get referrals from the same primary care physicians, their staff members are starting to understand what we mean by high risk and screening.

E/M Visit Not Covered for Screenings

Although gastroenterologists routinely conduct a complete history and examination of the patient prior to any colonoscopy, most carriers will deny attempts to bill an E/M service done in conjunction with a high-risk screening colonoscopy. We will bill Medicare for a consultation, but that usually gets denied because the screening is preventive in nature, says Peg Hopwood, a patient accounts manager at Rockford Gastroenterology, a nine-physician practice in Rockford, Ill. The reason we bill for the consultation is in case the gastroenterologist finds a polyp during the colonoscopy, and we end up billing a diagnostic procedure. Because the procedure is no longer preventative, the E/M visit will usually be reimbursed.

ICD-9 Codes Overlap for Both Procedures

Although the list of ICD-9 codes that may be used to establish the medical necessity of performing a high-risk screening colonoscopy will vary from carrier to carrier, most payers include many of the same diagnosis codes in the local medical review policies (LMRPs) for both high-risk screening and diagnostic colonoscopies. Chronic gastrointestinal conditions such as Crohns disease (555.x) and ulcerative colitis (556.x), for example, are usually covered diagnoses for both types of colonoscopies with most local carriers, and either procedure code could be reported.

Although covered diagnosis codes for both diagnostic and high-risk screening colonoscopies will vary from carrier to carrier, the ICD-9 codes that most commonly overlap both policies include the following:

V10.05 Personal history of malignant neoplasm of large intestine
V10.06 Personal history of malignant neoplasm of rectum, rectosigmoid junction and anus
V12.72 Personal history of colonic polyps
555.0 Regional enteritis, small intestine
555.1 Regional enteritis, large intestine
555.2 Regional enteritis, small intestine with large intestine
555.9 Regional enteritis, unspecified site
556.0 Ulcerative enterocolitis
556.1 Ulcerative ileocolitis
556.2 Ulcerative proctitis
556.3 Ulcerative proctosigmoiditis
556.8 Ulcerative colitis, other
556.9 Ulcerative colitis, unspecified
558.2 Toxic gastroenteritis and colitis
558.9 Other and unspecified noninfectious gastroenteritis and colitis

Bill for Diagnostic Colonoscopy When Possible

Although the relative value units for both procedures are nearly the same, gastroenterologists may want to report a diagnostic colonoscopy using 45378 when they have a choice. Then they will be able to bill and be reimbursed for an E/M service, says Albert Shaw, practice manager at Asher, Kornbluth MDPC, a three-physician gastroenterology practice in New York City.

A patient with active colitis (556.0-556.9) usually will have a complete E/M visit with the gastroenterologist before getting a colonoscopy, Shaw explains. During that visit, the gastroenterologist will discuss with the patient the status of his or her condition and more than likely will make some change in treatment, which should justify the billing of a separate E/M service.

Some Consider Follow-up as High-risk Screening

Other local carriers are changing their LMRPs to require that follow-up colonoscopies traditionally billed as diagnostic procedures now are billed as high-risk screenings. Most gastroenterologists will want a patient who has had a noncancerous polyp removed to return for a follow-up colonoscopy in two to three years, according to Martin. If the patient has no gastrointestinal symptoms and no new polyps are found during the procedure, Martin says to bill the follow-up colonoscopy as a high-risk screening and use the ICD-9 diagnosis code V12.72 (personal history of colonic polyps) on the claim.

AdminaStar, our local Medicare payer, does not include V codes (diagnosis codes used to designate a personal or family history) in its list of covered diagnoses for a diagnostic colonoscopy, Martin explains. So whenever a patient without symptoms has a colonoscopy, we bill it as a high-risk screening even if its a follow-up to a diagnostic procedure.

Other carriers are beginning to deny claims for follow-up colonoscopies performed on asymptomatic patients that are reported as diagnostic procedures, even when a diagnosis code specified by the LMRP is used. We used to be able to use V12.72 with either code, but now it will usually be denied by the carrier unless we report it as G0105, says Debbie Anderson, another patient accounts manager at Rockford Gastroenterology.

Even when the patient has a malignant polyp and part of the colon is resectioned, the follow-up colonoscopy six months later may be reported as a high-risk screening procedure with a diagnosis of personal history of malignant colorectal cancer (V10.00, V10.05 or V10.06) if the patient has no symptoms and no other polyps are found, Anderson adds.

In a situation where the patient has a high-risk screening with no signs of colorectal cancer, but develops gastrointestinal bleeding 18 months later and needs to have another colonoscopy, the second procedure should be billed as a diagnostic colonoscopy. Medicare should reimburse for this even though it is less than 24 months after the high-risk screening. The time limitation on the high-risk screening is measured from G code to G code, says Martin.

Precertify Screenings With Private Insurers

Despite the conventional wisdom that says commercial payers do not reimburse for high-risk screening colonoscopies, coding professionals are getting reimbursed by many of their commercial payers for this procedure. Just use the CPT code 45378 to report both the high-risk screening and the diagnostic colonoscopies, says Shaw. Commercial insurers dont recognize the HCPCS code G0105.

One key to getting reimbursed by a private payer is to precertify the high-risk screening procedure. We havent received a lot of rejections from private insurance, says Martin, probably because we call ahead and make sure this is part of the patients benefit package. Surprisingly, a number of insurance companies will pay for the high-risk screening.