General Surgery Coding Alert

Question: I read that Medicare has just changed its policy regarding screening vs. diagnostic colonoscopy, and that if the physician finds and removes a polyp during a screening, I should still report the screening diagnosis as primary. Is this true?


New York Subscriber

Answer: CMS officials caused some confusion last month by stating that you should still bill for a screening colonoscopy even after finding a polyp. But this was a mistake.

Clarification: Now CMS officials have set the record straight. -The policy is that if you find a polyp and remove it, you change to the diagnostic code,- says William Rogers, MD, a physician who heads the Physician Regulatory Issues Team at CMS. But you can still use the V code diagnosis (secondary to the diagnosis for the polyp) to indicate that the colonoscopy was a screening colonoscopy.

In other words: There's been no change in policy. If you find a polyp during a screening, the screening automatically becomes diagnostic.

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 (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).

Another consideration: If the surgeon finds a polyp during a screening, the patient is automatically at high-risk for colon disease and therefore qualifies for more frequent screenings. Also, if the physician feels the need to give the patient another colonoscopy, it will automatically be diagnostic, like a mammogram after a breast tumor.

A final note: If the physician finds a less serious problem, like diverticulosis or hemorrhoids, the screening colonoscopy should remain a screening test. The patient might qualify as high-risk and receive screening colonoscopies more often, however.