Gastroenterology Coding Alert

Question: We coded a patient's colonoscopy with V12.72 (Personal history of colon polyps) and V18.51 (Family history of colonic polyps). He was having no problems but came back for a repeat based on the type of polyps that the gastroenterologist removed. His insurance company is denying 100 percent of the claim because the representative told him we didn't code it as wellness. The agent states the diagnosis needs to be a screening code. What should I do?

Virginia Subscriber

Answer: You should code the intent of the visit, so your codes seem correct. Even though the insurance company denied the claim, that does not give you cause to change your codes. You have to code based on your physician's documentation, not an insurer's coverage requirements.

Bad news: Although Medicare considers your scenario a screening colonoscopy for high-risk, many private carriers consider the diagnosis a medical diagnosis.

Good news: Many coders bill it the way you did because this is the way Medicare says you should code it. You may try a letter of appeal and attach documentation from the January 2004 CPT Assistant as well as Medicare's guidelines. You should demonstrate that this colonoscopy was screening. Obviously the error is on their part. If your patient is saying you were the one who made the error, then copy the patient on the appeal as well.

Note: You can try adding V76.51 (Special screening for malignant neoplasms; colon) as a tertiary code, not as a primary one.