Gastroenterology Coding Alert
Multiple Techniques Equal Multiple Payments?
Question: A patient comes into the office and wants a colonoscopy screen. He cites a family history of colon polyps as a matter of concern. Is this family history sufficient for choosing a V code diagnosis and for reimbursement for a colonoscopy? If so, which code should I use? Answer: Generally, a history of colon polyps will not provide a sufficient diagnosis to gain reimburse-ment, especially from most Medicare carriers. However, this does vary from state to state and carrier to carrier, so check with your local carriers to verify what, if any, family history code will be acceptable as a diagnosis warranting colonoscopy.
Idaho Subscriber
Coders report a variety of V codes to justify colonoscopies for patients with family history of colon polyps. Code V18.5 (Family history of certain other specific conditions; digestive disorders) is perhaps the most popular. Other codes reported to have been used include V76.50 (Special screening for malignant neoplasms; intestine, unspecified), V76.51 (... colon) and V19.8 (Family history of other conditions; other condition).
Many carriers will not consider these family history diagnoses as placing the patient in a high-risk category. For instance, Georgia's Medicare carrier in the Atlanta area will not pay for any of the codes above for colonoscopy. They designate the following codes as constituting high risk on the patient's behalf and thus warranting colonoscopy screen:
Georgia's policy lists family history of colon cancer as high risk, but the other diagnoses would not hold up. If you're submitting without the patient classifying as high risk for cancer, Medicare instructs you to "down-code": Use the HCPCS procedure code G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk), a low-risk screen.
Another critical factor for payment of colonoscopy for Medicare is timing. Medicare considers high-risk patients to be eligible for a colon screening every 24 months.
Gastroenterology Coding Alert
- 5 Steps to Foolproof Hemorrhoid Coding
Coding Tips to Help Increase Your Confidence and Reimbursement Gastroenterologists frequently manage hemorrhoids, yet those [...] - Coder to Coder:
10 Tips for 'Getting It Right' Every Time
Use This Field-Tested Checklist to Make Your Work More Efficient and More Effective Gastrointestinal coding [...] - You Be the Coder:
Multiple Techniques Equal Multiple Payments?
Question: A patient comes into the office and wants a colonoscopy screen. He cites a [...] - Reader Question:
Signs, Symptoms and E Codes - Oh My
Question: A primary-care physician (PCP) sent a patient to us for a consult. The request [...] - Reader Question:
A Screen Is a Screen Is a Screen
Question: We screened a Medicare patient for colorectal cancer with a fecal-occult blood test. She [...] - Reader Question:
FYI on NCCI: Use the Right Edits
Question: Which National Correct Coding Initiative (NCCI) edits should we use - Medicare's or the [...] - Reader Question:
Render an Opinion on Confirmatory Consults
Question: Can a transfer of service take place when we conduct a confirmatory consult? How [...] - Think You've Made Your Case for Modifier -22? Not if You Haven't Done These 5 Things
If you're submitting claims for unusual procedural services without first determining how you're going to [...] - Reader Question:
Choose Your Coding Poison Based on Documentation
Question: How should I decide whether managing excessive bleeding that requires extra physician time and [...] - Test Yourself:
Opt for -22 Over an Unlisted-Procedure Code
Question: Our physician asks us to report procedures that take extra time and effort with [...]
