Gastroenterology Coding Alert

Question: We have a patient that came in 2002 for a screening (referred by his primary care physician [PCP]), and we found adenomas polyps. The patient came back for a follow-up in 2005; this time we found hyperplastic polyps. For his 2011 follow-up visit, we didn't find any polyps. We coded with V12.72 as primary diagnosis. The procedure report stated follow-up for history of adenomas polyps. However, when I checked the patient's chart, I learned that he changed primary care physicians just before he came back for his first follow-up. Now his new PCP wants us to change the ICD-9 code to V76.51 so that the insurance will cover 100 percent. What would be your advice?

Florida Subscriber

Answer: If a patient has a documented history of polyps, then the PCP has that history, and hiding that fact could be considered fraud. The recent healthcare legislation provided patients with certain preventative healthcare benefits that are not subject to deductibles. A routine colonoscopy for average risk screening is a covered preventative service subject only to the co-payments under the patient's plan. Unfortunately the legislation did not allow the same coverage for high-risk colonoscopy surveillance procedures performed because of family history of colon cancer (V16.0) or because of a personal history of colon polyps (V12.72). Colonoscopies performed to evaluate symptoms or signs are treated like high-risk surveillance colonoscopy examinations. These procedures are subject to deductibles and for patients with high deductible plans that might mean they are responsible for 100 percent of the allowed fee.

We cannot hide the medical information just to increase payments from the carrier and save the patients from deductibles. You cannot use V76.51 with any other colorectal neoplasia V code or with any other symptom code that is considered an indication for colonoscopy (diarrhea, occult bleeding, etc). You will need to be diplomatic when discussing this with the referring PCP but these are the rules. You must code based on your documented information. If you don't know some piece of information, and therefore haven't documented some piece of information, then you can't be faulted for not coding that information.