Medicare Compliance & Reimbursement

CMS officials start backtracking on February clarification.

If you thought your doubt and confusion about screening colonoscopy billing was a thing of the past--think again.

Clarification: Back in February, CMS officials clarified that when a screening colonoscopy finds a polyp, you should bill using the polyp diagnosis, not the screening "V" code. But now CMS officials are distancing themselves from that instruction.

Reversal: Officials now point to language in the ICD-9 diagnosis coding guidelines, which state that you should still use the screening diagnosis even if you find a problem during a screening exam. "Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis," the ICD-9 manual states.

"I didn't mean to say anything that was contrary to the guidance that CMS has given on this subject," says William Rogers, head of the Physician Regulatory Issues Team. But some coding experts point out that the ICD-9 guidance is mostly tailored to hospitals, which use ICD-9 codes for billing.

Carrier guidance: Most carriers have come out in favor of switching to the polyp diagnosis for the excision, say coders. But Trailblazer Health Enterprises has come down on the side of keeping the "V" code even if you find a polyp.
 
The January 2004 CPT Assistant also came down on the side of putting the polyp diagnosis first when the physician finds a polyp and performs a therapeutic procedure, notes Chris Felthauser, medical coding instructor for Orion Medical Services in Eugene, OR.

Officials Question Screening Exams' Effectiveness

CMS officials "want to know whether or not screening exams actually accomplish what they are intended to do: catch potentially cancerous polyps and lesions and get them treated before they have a chance to become dangerous," says Jo Ann Steigerwald, a coding consultant with Medical Business Specialists in Baraboo, WI.

The problem: If you list the screening "V" code first, then most Medicare carriers won't pay for the polypectomy, says Barbara Cobuzzi, president of CRN Healthcare Solutions in Tinton Falls, NJ. Most carriers don't have the screening code listed as a covered diagnosis for diagnostic colonoscopy in their local coverage determinations.

Some experts have recommended listing the "V" code as the primary diagnosis in Box 21 of the claim form, but then including a "2" next to the procedure code in Box 24. This will let the carriers know that the secondary diagnosis, the polyp code, is the one that should be associated with the procedure code. But Cobuzzi says this won't work with most billing software.
 
Bottom line: For now, you should follow your carrier guidelines, says Felthauser. If your carrier tells you to list the polyp diagnosis first, go ahead and do that. Afterall, the carrier is the one who decides whether you'll get paid.