Medicare Compliance & Reimbursement

You may be surprised by Medicare's guidance on diagnosis codes If you're confused about what constitutes a screening versus a therapeutic colonoscopy and how to order your ICD-9 codes, you're not alone. Four scenarios break down the Centers for Medicare & Medicaid Services' (CMS) stance on this tricky subject and help lead to picture-perfect colonoscopy claims. Secure What a Screening Procedure Entails Scenario 1: A Medicare patient with no gastrointestinal symptoms reports for a screening colonoscopy (or flexible sigmoidoscopy). The gastroenterologist performs the procedure and sees nothing out of the ordinary. Solution: This is a screening procedure. CMS waives the annual Part B deductible for colorectal cancer screening tests. For the procedure code, 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. Use G0104 (Colorectal cancer screening; flexible sigmoidoscopy) if the physician performs a screening flexible sigmoidoscopy. As for the diagnosis, your primary ICD-9 code should be a screening V code. The only code for individuals not meeting criteria for high risk is V76.51 (Special screening for malignant neoplasms; colon). In other words, you'll use V76.51 for low-risk patients. For high-risk patients, you might use V10.05 (Personal history of malignant neoplasm; large intestine), V10.06 (... rectum, rectosigmoid junction, and anus) or V16.0 (Family history of malignant neoplasm; gastrointestinal tract). Know How to Code Contrast Screening Scenario 2: A Medicare patient with no gastrointestinal symptoms reports for a screening colonoscopy (or flexible sigmoidoscopy). The gastroenterologist performs the procedure and sees an abnormality (such as a polyp or lesion), which he biopsies or removes. Solution: This is a screening procedure that turned into a therapeutic procedure. You cannot report this procedure as a screening, nor can you waive the deductible. In this case, you should use the code for the actual procedure and not the G screening code. For instance, if the physician discovers a polyp during the colonoscopy, you should report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple). If the physician performs a flexible sigmoidoscopy, you'll report 45330-45345. As for the diagnoses, the primary diagnosis should be the screening code: V76.51. Your secondary diagnosis code should reflect the abnormal finding -- for instance, 211.3 (Benign neoplasm of other parts of digestive system; colon). "This way tells the payer that this was a screening colonoscopy and that the physician found a polyp(s) during the exam," says Debora K. Schulte, CPC, a medical coder at UCSD Medical Group Business Services in San Diego. Helpful hint: Enter a "2" in Box 24E of the CMS 1500 to link the [...]