Gastroenterology Coding Alert

Changes may be on the horizon for virtual colonoscopies, thanks to an American College of Radiology Imaging Network (ACRIN) trial, and it's up to you to be up-to-date on all of gastroenterology's new technologies.

Here's what you need to know about reporting these services now.

What they are: CT colonography (virtual colonoscopy) is an enhanced abdominal CT scan in which computer reconstruction allows physicians to perform a detailed longitudinal 3-D examination of the bowel for polyps, cancer, or other disease. This procedure uses helical computed tomography of the abdomen and pelvis to visualize the colon lumen, along with 3-D reconstruction. Note: The test requires colonic preparation similar to that required for standard colonoscopy (instrument colonoscopy) and air insufflation to achieve colonic distention.

For this service, you'll report CT colonography codes 0066T (Computed tomographic [CT] colonography [i.e., virtual colonoscopy]; screening) or 0067T (... diagnostic), says Kelli Pekios, patient accounts manager at Gastroenterology Consultants SC in Moline, Ill.

Important: These Category III codes are global codes, meaning they include both the technical (modifier TC, Technical component) and physician reading fee (modifier 26, Professional component). Therefore, to bill for the whole service, your gastroenterologist needs to have training in reading CT scans and colonography.

Medicare does not cover 0066T, the CT colonography code for screening. However, CMS periodically revises screening benefits, and many think this may soon change.

Here's why: "Most physicians and much of the public have embraced full colon imaging as the optimal colorectal cancer prevention approach, because the whole colon is at risk and because polyp detection and removal prevents cancer before it starts," says Douglas K. Rex, MD, professor of medicine and director of endoscopy in the Division of Gastroenterology & Hepatology at Indiana University Medical Center in Indianapolis.

"With the publication of the American College of Radiology Imaging Network trial, guideline groups will likely reconsider CTC as an option for screening" and you'll see a "renewed pressure for a Category I CPT code," Rex says.

However, you may have more luck with receiving reimbursement for diagnostic CT colonographies (0067T), but you'll have to get your supporting ICD-9 codes and documentation in perfect order.

For example, National Heritage Insurance Company (NHIC) of Indiana "does not consider routine use of CT colonography for diagnosis to be an established intervention that is reasonable and necessary." Instead, NHIC considers CT colonographies medically necessary when "diagnostic optical colonoscopy has failed or is incomplete due to obstruction, and where the results of CT colonography are likely to impact further patient management."

In other words, when a patient with signs or symptoms of a disease undergoes an incomplete diagnostic optical colonoscopy (because of neoplasm, stricture, tortuosity, spasm, redundant colon diverticulitis, extrinsic compression or aberrant anatomy scarring from prior surgery), your gastroenterologist may turn to CT colonography (0067T) as a solution.

Note: To prevent the patient from having to endure repeat colonic preparation, your gastroenterologist will likely perform the CT colonography soon after the failed standard colonoscopy.

Supporting diagnoses: You would provide V64.3 (Procedure not carried out for other reasons) when the physician attempted an instrument colonoscopy but did not complete the service or when the physician determined from a patient evaluation that he cannot safely attempt an optical colonoscopy. However, you'll need to provide a secondary diagnosis as a reason why the physician could not carry out the procedure. For instance, your documentation might support including 211.3 (Benign neoplasm of colon) as your second diagnosis.

Documentation-must: You must have documentation for both the virtual colonoscopy and the failed colonoscopy (available upon request).

You'll run into trouble if you try to report 0067T with these limitations.

First of all, you won't run into any reimbursement down the road if you report 0067T with V76.51 (Special screening for malignant neoplasms; colon). This code refers to a diagnostic procedure, not a screening one.

Second, because any colonography with abnormal or suspicious findings requires a colonoscopy for diagnosis (such as a biopsy) or treatment (such as a polypectomy), payers will not pay for CT colonographies as an alternative to a colonoscopy -- even though your gastroenterologist may have performed this service for signs or symptoms of a disease.

"Irritable bowel syndrome and abdominal pain when representing chronic stable symptoms rarely represent reasonable indications for colonoscopy and CT colonography," according to NHIC. However, you can use them as diagnoses "when a colonoscopy/colonography exam is normal in the face of compelling symptoms." But watch out -- your physician will have to carefully document the rationale in the medical record.

Best advice: "Watch your insurance companies for criteria, because they are very strict -- especially Medicare," Pekios says.