Radiology Coding Alert

Question: Do we need to obtain an advance beneficiary notice (ABN) for virtual colonoscopy services?

Florida subscriber

Answer: Your best bet is to ask your payer, but you may prefer to play it safe when dealing with virtual colonoscopies by making sure you get a signed ABN.

Medicare only pays for screening services if the rules oblige them to, like screening mammography, so don't bank on getting a virtual colonoscopy covered. You have a better chance of reimbursement if you show that the test was performed because of signs or symptoms, like positive blood in the stool. For example, Empire Medicare, one of the largest Medicare contractors in the country, recently decided to cover virtual colonoscopy when a regular colonoscopy fails due to an obstructing lesion.

In any case, obtaining written documentation that the patient may be responsible for the charges is generally a good idea. 

Don't forget: Add modifier -GA (Waiver of liability statement on file) to show you have an ABN or add -GZ (Item or service expected to be denied as not reasonable and necessary) to show that you don't, and the patient can't be billed. If a carrier does not consider a service to be reasonable and necessary, and the doctor did not have the patient sign an ABN agreeing to pay for the service, the doctor cannot bill the patient after the carrier denies payment. The main point to remember is that virtual colonoscopies are likely going to be denied, and your radiologist doesn't want to end up paying for them.

In July 2004, CMS implemented category III codes for virtual colonoscopy, 0066T (Computed tomographic colonography [i.e., virtual colonoscopy]; screening) and 0067T (... diagnostic). The only real guidance given was not to report 0066T or 0067T in conjunction with 72192-72194, 74150-74170, or 76375. (See www.ama-assn.org/ama/pub/article/3885.html for the list). Category III codes are important to let healthcare professionals identify the use of emerging technologies, but not everything that gets a code is considered medically necessary, so it really is best to ask the payer. Still, keep in mind that CPT guidelines say that "if a Category III code is available, this code must be reported instead of a Category I unlisted code."