General Surgery Coding Alert

A recent CMS Transmittal has called an end to conflicting guidelines on how to diagnose a screening colonoscopy during which the physician finds a polyp or other abnormality. Coders should find relief in the CMS announcement: The issue of how to report a "screening-turned-diagnostic" has caused confusion for years.

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.

Pick your dx: You will assign a V code as the primary diagnosis with any screening colonoscopy. For low-risk patients, you should cite V76.51 (Special screening for malignant neoplasms; colon).

When reporting G0105, however, you must supply evidence to support the patient's "high-risk" status. Some diagnoses that Medicare considers high-risk factors for colorectal cancer, and that therefore justify a high-risk screening, include:

             - 555.0 -- Regional enteritis; small intestine.

Note: This is not an exhaustive list of diagnoses that payers may accept for G0105. Check with your individual payer for its guidelines.

When a screening exam uncovers a polyp, you will turn away from the G codes to report the procedure and instead select an appropriate category I CPT code, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Example: The physician begins a screening colonoscopy for an average-risk Medicare patient. She then finds a polyp, which she biopsies.

In this scenario, you should choose 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple), without any modifiers, rather than G0121.

In other words: If during the screening colonoscopy the physician detects a lesion or growth that results in a biopsy or removal of the growth, you should bill, and be paid for, the appropriate diagnostic procedure (45380) rather than G0121.

An important point to remember, however -- and the subject of the recent CMS clarification -- is that you should retain the initial V code as the primary diagnosis, even if the physician finds a polyp and performs a diagnostic colonoscopy during the screening exam.

"Whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination," states Medicare Learning Network (MLN) Matters article SE0746, "Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscopy."

"This new CMS directive is a relief," says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky. "The issue of how to report a -screening-turned-diagnostic- has confused a lot of practices. So many different specialties are involved in colonoscopy coding -- not just performing them but writing orders for them -- that a clarification was badly needed."

This Medicare scenario assumes that an asymptomatic patient presents for a screening colonoscopy (or flexible sigmoidoscopy), and during the subsequent screening colonoscopy (or flexible sigmoidoscopy), the physician identifies an abnormality (such as a polyp) that he then biopsies or removes.

Report the polyp dx as secondary: The official ICD-9 coding guidelines stipulate, "A screening code may be a first-listed code if the reason for the visit is specifically the screening exam - Should a condition be discovered during

the screening, then the code for the condition may be assigned as an additional diagnosis" [emphasis added].

"I agree with this method of assigning a diagnosis, and am glad that CMS has better clarified its recommendations. Now, the problem is getting other payers to play under the same guidelines," says Willie J. Winer, RHIT, CCS, coding manager with Health Information Services at Lawrence General Hospital in Lawrence, Mass.

"I am glad to see that CMS is incorporating the official coding guidelines into its instructions for coding screening colonoscopies," says Stacey Radick, RHIT, CCS, coding consultant and proprietor of Opticode in Vashon Island, Wash.

Coding example: During a screening exam for a patient at average risk of colorectal cancer, the physician discovers a polyp and performs a biopsy. In this case, you would report an appropriate diagnostic colonoscopy code (such as 45380).

As a primary diagnosis, you would cite V76.51. You may cite the polyp diagnosis (for instance, 211.3, Benign neoplasm of other parts of digestive system; colon) as a secondary diagnosis.

Primary resource: You can view MLN Matters SE0746 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/se0746.pdf.