Gastroenterology Coding Alert

Warning: Leaving off the V code for high-risk patients could cost you

If you think V codes aren't vital to your claims for colorectal cancer screening services, prepare to face denials due to lack of necessity. 

Why? The coder must assign the most precise diagnosis codes to reflect the physician's narrative description of the symptom or diagnosis, experts say. In many cases, that precision requires V codes because they often identify reasons for medical encounters for other than disease or injury.

Don't miss an opportunity: "I really believe reporting V codes is underutilized, especially in the outpatient setting," says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.

Note: You should check the Medicare Web site for the complete list of acceptable V codes for high-risk patients.

For a high-risk patient older than 50, Medicare will pay for a colorectal cancer screening once every two years. But to identify a patient as high-risk, you must include a V code on the claim.

Coding truth: If the gastroenterologist performs a colorectal cancer screening on a 50-year-old high-risk Medicare patient, experts recommend:

• reporting G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for the high-risk cancer screening.
• linking the appropriate V code to G0105. Some V codes that prove medical necessity for G0105 are V10.05 (Personal history of malignant neoplasm; large intestine), V10.06 (... rectum, rectosigmoid junction, and anus) and V16.0 (Family history of malignant neoplasm; gastrointestinal tract).

Coding consequences: If you don't report the V code for personal or family history, Medicare will deny the G0105 claim. Include a V code on every colorectal cancer screening for high-risk Medicare patients.

You should also use V codes when the gastroenterologist provides a pre-colonoscopy screening for an asymptomatic Medicare patient. Gastroenterologists commonly perform this screening before an average-risk colorectal cancer screening (G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Example: A new Medicare patient calls and wants a colorectal cancer screening. The patient is not high-risk, but before scheduling the colonoscopy the gastroenterologist still examines the patient for risk factors that may endanger him during the screening. The patient has no such factors, so the gastro approves the patient for the procedure.

This type of visit is typically a level-one service. If your office reports an E/M code for this procedure, you should report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making) with V72.83 (Other specified preoperative examination) and V76.51 (Special screening for malignant neoplasms; colon) attached. 

Why? The V codes prove to Medicare that the doctor performed the E/M service to ensure patient safety before a colorectal cancer screening on a new patient.

Note: CMS has said that the pre-op E/M is "medically necessary" to rule out any underlying medical conditions that could put the patient in jeopardy during a surgical procedure.

Unfortunately, national policy about the colorectal screening benefit also stipulates that Medicare does not cover an E/M service for an asymptomatic patient prior to a screening colonoscopy. This means that Medicare will not pay for 99201 for an average-risk patient. You can bill the patient, however, if you obtain an advance beneficiary notice (ABN) before the service.

What it is: An ABN is a written notice that informs the beneficiary (that is, the patient) that Medicare might not cover a particular service or procedure. Signing the waiver shows that the patient acknowledges he may have to pay for the procedure or service if Medicare does not -- if you document his treatment correctly, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher. See future issues of Gastroenterology Coding Alert for tips and strategies that will help you with ABNs.