Part B Insider (Multispecialty) Coding Alert

Question: My gastroenterologist performed a colonoscopy on a patient who is less than 50 years old with a V16.0 diagnosis. He doesn't have coverage for screening colonoscopy because of his age, but his insurance considers V16.0 a medical diagnosis and could have paid for the service. The colonoscopy revealed no findings. Why did the insurance deny my claim when I billed V16.0 with 45378?

Answer: You should have determined the benefits for the procedure and verified the payment before performing it on the patient. Colonoscopy procedures in patients without active symptoms do not qualify as an emergency and the best way to make sure that the physician is paid for the service is to get phone verification of benefits.

Moreover, regulation doesn't require insurance coverage for high-risk screening colonoscopy.

Although some insurers would accept G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) instead of 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]) to qualify for screening benefits, you shouldn't bill it UNLESS the insurance company representative instructed it during the verification process. Commercial carriers for non-Medicare patients do not generally recognize G0105, which is a CMS code.

Purpose: G0105 is a CMS HCPCS code that applies for screening of a patient that has a high-risk for colorectal neoplasia. Examples would be universal ulcerative colitis (556.6) or a history of malignant neoplasm of the lower gastrointestinal tract (V10.0). You should report this HCPCS code when the service reveals no findings.

No modifier would be appropriate to use on 45378 if you insist on using this code. Just the same you could try sending in all notes with your claim. If the patient was referred for the procedure, you might want to ask the referring physician if she would write a letter validating medical necessity.