General Surgery Coding Alert

Carriers differ on primary diagnosis for -diagnostic- screenings

The confusion over how to report screening colon-oscopies that become -diagnostic- has intensified further over the past several months. With no end to the debate in sight, your only answer may be to ask for written instructions from your individual carrier.
 
Background: In February, CMS officials clarified that when a screening colonoscopy finds a polyp, you should bill using the polyp diagnosis, not the screening V code. (See Reader Question, -Screening-vs.-Diagnostic Rules Haven't Changed- on page 39 of the May 2006 General Surgery Coding Alert.)
 
Example: For Medicare patients, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for an average-risk patient receiving a screening colonoscopy, or G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for a high-risk patient.
 
But if the physician discovers a polyp during the screening, you should instead report a diagnostic colonoscopy ( CPT 45380 , Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).
 
And when the surgeon visualizes and biopsies the polyp, you should change the primary diagnosis from V76.51 (Special screening for malignant neoplasms; colon) to, for instance, 211.3 (Benign neoplasm of other parts of digestive system; colon), as outlined in the instructions CMS provided in February.
 
The retraction: Now, CMS officials are distancing themselves from their earlier instruction, pointing to language in the ICD-9 diagnosis coding guidelines that state that you should still use the screening diagnosis even if you find a problem during a screening exam.
 
-Should a condition be discovered during the screening, then the code for the condition may be assigned as an additional diagnosis,- according to ICD-9 instructions.
 
-I didn't mean to say anything that was contrary to the guidance that CMS has given on this subject,- says William Rogers, MD, head of CMS- Physician Regulatory Issues Team.

If in Doubt, Ask for Guidance

Most carriers have come out in favor of switching to the polyp diagnosis for the excision. But a few, including Trailblazer Health Enterprises, have come down on the side of keeping the V code even if you find a polyp during a screening.
 
In addition: The January 2004 CPT Assistant (published by the AMA) also came down on the side of putting the polyp diagnosis first when the physician finds a polyp and performs a therapeutic procedure, says Chris Felthauser, medical coding instructor for Orion Medical Services in Eugene, Ore.
 
Watch out: A serious problem can occur if you list the screening V code first, because many Medicare carriers won't pay for the polypectomy, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. Most carriers don't have the screening code listed as a covered diagnosis for diagnostic colonoscopy in their local coverage determinations.
 
Possible solution: Some experts have recommended listing the V code as the primary diagnosis in Box 21 of the claim form, but then including a -2- next to the procedure code in Box 24. This will let the carriers know that the secondary diagnosis, the polyp code, is the one that they should associate with the procedure code. Cobuzzi warns, however, that this won't work with most billing software. 
 
Bottom line: For now, you should follow your carrier guidelines -- whatever they may be -- Felthauser says. If your carrier tells you to list the polyp diagnosis first, do that. But with so many conflicting opinions circulating, you-ll want to be sure to get the carrier's instruction in writing: That way, you-re covered no matter what happens in the future.