General Surgery Coding Alert

Question: We had a patient who had a colonoscopy for personal history of colon cancer (V10.05), but the patient’s insurance plan doesn’t recognize that code for screening benefits, so the diagnostic benefit applied and the patient had to pay out of pocket expenses. Is there anything we can do to avoid this?

Texas Subscriber

Answer: Regardless of findings, it is essential to stick to V10.05 (Personal history of malignant neoplasm of large intestine) when the colonoscopy is ordered because the patient has had a history of colon cancer.

If you’re billing Medicare, you should report the procedure as a high risk screening with code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). Then, report V10.05 as the primary diagnosis.

On the other hand, some commercial carriers would requireV10.05 as diagnosis and 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) with modifier 33 (Preventive services) to denote that the service was preventive.

“CPT^®modifier 33 has been created to allow providers to identify to insurance payers and providers that the service was preventive under the applicable laws, and that patient cost-sharing does not apply,” according to AMA. This means that a patient’s co-insurance, co-payment, and deductible are waived for the applicable services (in this case, 45378). All commercial carriers and Medicare payers should be in compliance with these rules as established in the Affordable Care Act.

List V10.05 as your primary diagnosis for both circumstances (Medicare and commercial payers), whether the results were clear or not. Don’t report a cancer code (153.3,Malignant neoplasm of sigmoid colon) or the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract) as the primary diagnosis.