General Surgery Coding Alert

Recent CMS instruction has ended confusion over how to diagnose a screening colonoscopy that turns into a colonoscopy with polyp removal, but there remains one potential pitfall for coders preparing these claims. Get the complete facts here to avoid a crucial mistake.

If a service to a Medicare beneficiary starts out as a screening examination, "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," dictates Medicare Learning Network (MLN) Matters article SE0746, "Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscopy."

Cite neoplasm as secondary: MLN Matters SE0746 further instructs that if the physician finds a neoplasm during a screening exam, you should "indicate the secondary diagnosis using the ICD-9-CM code for the abnormal finding (polyp, etc.)."

Example: During a previously scheduled screening colonoscopy for a Medicare patient, the physician discovers several polyps, which he removes immediately by snare technique (e.g., 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s] or other lesion[s], by snare technique).

In this case, because the service began as a screening, you would assign the screening V code (for instance, V76.51, Special screening for malignant neoplasms; intestine; colon) as the primary (first-listed) diagnosis. You would then list an appropriate ICD-9 code to describe the neoplasms the physician removed (for example, 211.3, Benign neoplasm of other parts of digestive system; colon) on the second line.

Although you should list the screening diagnosis first on your claim form, your diagnosis pointer should nevertheless link the appropriate polyp diagnosis to the diagnostic colonoscopy CPT code, says Diane O-Brien, a nearly 40-year veteran insurance coder and coordinator with Surgical Associates in Warner Robins, Ga.

CMS explicitly requires this coding. In an example of a screening-turned-diagnostic colonoscopy, MLN Matters SE0746 instructs coders to enter a "2" in the diagnosis pointer (Item 24E on the CMS-1500 claim form), thus linking the CPT procedure code to the "line 2" diagnosis (that is, the polyp). Further language in the article makes clear that the "2" in Item 24E is "to link the procedure (polypectomy or biopsy) with the abnormal findings (polyp, etc.)."

Therefore, for our example above of a diagnostic colonoscopy (45385) that began as a screening, with a primary diagnosis of V76.51 and a secondary diagnosis of 211.3, you would enter V76.51 in box 21 (1) of the CMS-1500 claim form. In 21 (2), you would list 211.3. In item 24.1.d, enter 45385. Finally, place a "2" in box 24.1.E.

CMS- convoluted method of reporting diagnoses for screening-turned-diagnostic colonoscopies may leave practices with certain billing systems in a lurch -- meaning that you may have to seek alternative solutions.

"Our computer system is not compatible with this format [of linking the procedure code to a secondary diagnosis]," O-Brien says. Therefore, the only way to "link the procedure (polypectomy or biopsy) with the abnormal findings (polyp, etc.)," as CMS instructs, is to list the polyp diagnosis as primary, she says.

Although she hasn't seen denials arising from this problem yet, O-Brien is concerned. "We are still working with your clearinghouse to resolve this issue," she says.

Best bet: If your billing system won't allow you to follow CMS- instructions regarding diagnosis coding for a screening colonoscopy turned diagnostic, contact your payer immediately and ask for guidance on how to move forward.

Learn more: For additional information on screening-turned-diagnostic colonoscopies -- including instructions on CPT coding for these services -- and MLN Matters SE0746, see General Surgery Coding Alert, Vol. 10, No. 6, "Once a Screening, Always a Screening, CMS Says," pages 43-44.