Gastroenterology Coding Alert

Question: When a patient is referred to our physicians for evaluation for a screening colonoscopy, we bill a consultation. If no history of present illness exists, should I report a preventive medicine code instead?

California Subscriber

Answer: CMS Transmittal 1719 establishes that prescreening diagnosis codes V72.81-V72.84 are not routine services, and carriers may not deny them as routine. However, the codes do not automatically establish medical necessity, which is subject to Medicare Carriers Manual section 15047H. MCM says that using supporting ICD-9 codes that prompted the preoperative medical evaluation helps explain the visit as reasonable and necessary. The section does not further define any criteria for medical necessity and, absent any national coverage, leaves the issue to carrier discretion. Therefore, we need to examine logically whether medical necessity exists for a referred prescreening evaluation.

If, before sending the patient to your practice, the referring physician evaluates the patient and clears him for the procedure, the examination in your office does not constitute medical necessity.

For example, a patient visits his family doctor for an annual examination. The doctor recommends that the patient have a screening colonoscopy and refers the patient to your practice with a note stating that no history of present illness exists.

The service does not qualify for medical-necessity guidelines, because the referring doctor already examined the patient and cleared him for the procedure. Notation that "no history of present illness exists" indicates that a prescreening examination was already conducted. In contrast, if any underlying conditions existed, the family doctor would note these on the referral.

However, if the referring physician did not examine the patient and referred him to you directly, an examination may be warranted.

For instance, a patient reads about the importance of having a screening colonoscopy and calls his primary-care provider, who refers him to your practice. The gastroen-terologist conducts a complete history, including personal, family and social histories and a physical examination, and decides whether the patient is healthy enough to have a colonoscopy.

No preoperative examination was conducted to ensure the patient could tolerate the procedure. Therefore, the gastroenterologist provided a medically necessary, reportable service. You should report the appropriate office visit code (99201-99205, New patient office visit; 99211-99215, Established patient office visit). Link the office visit code to the diagnosis code for preoperative exams (V72.81, Preoperative cardiovascular examination; V72.82, Preoperative respiratory examination; V72.83, Other specified preoperative examination; V72.84, Preoperative examination, unspecified).

You should still have the patient sign an advance beneficiary notice in case the insurance company denies the medical necessity of the examination. The waiver should explain that the carrier may not pay for the preoperative evaluation and that the patient may be responsible for payment.

The visit does not constitute a consultation (99241-99245). The primary-care provider did not request an opinion on the patient; she simply recommended a screening procedure for the patient.

In addition, a preventive medicine code (99381-99397) describes a more complex examination. "These codes are categorized by patient age, largely because they were developed with input from physician advisers who felt that the types of services provided in a preventive visit vary by the age of the patient," states CPT Assistant August 1997. They encompass a broader, age-specific examination, which includes a variety of "history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures."

A preoperative evaluation for a screening colonoscopy is simply to verify that the patient is healthy. It does not include a comprehensive history and examination, and the gastroenterologist is not making medical decisions as to whether the patient may qualify for other diagnostic procedures.

Note: Visit www.hcfa.gov/pubforms/transmit/r1719b3.pdf for a copy of the transmittal. Adobe Acrobat Reader, available free of charge from medville.com, is required to open the file.