Wiki Anthem BC/BS colonoscopy

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newhall94

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I have a 55 year old patient who has Anthem for their insurance, he presented to us for a straight colonoscopy, with no findings. So we coded it 45378 with v76.51 as the diagnosis. Anthem is saying because it wasn't coded as a screening he has to pay co-insurance fee. Of course they won't tell you what codes are their screening codes, only will tell the patient we coded it wrong. So my question is, does anyone know another screening code.

Thanks!
 
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You coded this correctly. You just might want to add the 33 modifier and see if that helps. Insurance companies will always tell the patient that the doctor coded it wrong. I get this alot. If the benefits state that a screening is to pay at 100%, then you will have to appeal this. Also did you call the insurance or did you just get this from the patient? I have called insurance companies and had them reprocess the claim.
 
I thought the modifier 33 was for a screening colonoscopy turned diagnostic? The colonoscopy was a preventative screening one. The doctor listed that as the reason for the visit. The insurance company won't tell us anything but told the patient that the V76.51 code is correct but that in addition to that we need to tell them that it was preventative. Would that be a V70.0?
 
Sorry, your right about the 33 modifier, I had a brain fart. The coding is correct. You need to call the insurance, they are incorrect. V76.51 is the only code to use for screening, there is no other code to use. You wouldnt use the V70.0. This is something you are going to have to appeal. The one thing you have to remember is the people you talk to on the phone at the insurance company and that the patients talk to have no idea about coding. I have had insurance companies try to tell me that there is a screening code other than the 45378 and they are wrong. I had to appeal these claims and I got them paid.
 
First off newhall94, the last sentence in your first post? Forget about it. We all want to make it better but we have to code correctly. It is fraud if you knowingly change a code to get a higher reimbursment or to make it easier on the pt. I know that wasn't your intention by typing that (I hope), but it's a thought we can't have. We have to enter the codes that are correct according to the documentation.

Now, on to your question. Technically, you could use the G codes (G0121-average risk, or
G0105-high risk). They are HCPCS codes for Medicare, but some payors will reimburse for them.

Now you say he presented to you for a straight colonoscopy and there were no findings. Did he present for a screening? Or did he have symptoms (abd pain, diarrhea, etc)?

Onto the 33 modifier. 45378 is a diagnostic procedure code, so again, techinically, you could use the 33 modifier but you shouldn't have to. You did code the procedure correctly the first time and it sounds like you will need to call Anthem BCBS.
 
Let's be clear, I am not talking fraud here, I wouldn't take part in any of that! I am simply stating I knew it was coded correctly, I'm tired of the insurance companies playing their games to hold onto the money when it's not their's to hold on to. That's all I'm saying. I think we can all agree insurance companies can be difficult to deal with.

As I stated above the patient presented for a screening colonoscopy, no other symptoms. I had wondered about the G-codes, I think Anthem is good for that. I'm thinking that's what they are meaning. We'll try those, thanks for letting me bounce ideas.
 
:eek:I'm sorry to make it sound like I was accusing you, that wasn't my intention. I tried to post it in such a way that it would show, that simply, we can't even think those words,
So my question is, does anyone know another screening code that we could use so this patient won't have to pay as much?
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Again, I apologize. But if it can slip out here, it can slip out in the office and if it slips out in front of the wrong person there........

Anyhows, good luck with this. Like a couple of us said, you had the right of it the first time and shouldn't have to go through this now, but like you said:

I'm tired of the insurance companies playing their games to hold onto the money when it's not their's to hold on to. That's all I'm saying. I think we can all agree insurance companies can be difficult to deal with.
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I know, I should have worded it that...he has full coverage(I saw his policy) for a preventative/screening colonoscopy but only if it's coded by their standards. I don't know what their standards are, I'm trying to figure that out. I thought a v76.51 was good enough but for BC/BS it is not...I'm not giving up, I will figure it out and when I do I'll be sure to post it here so others don't have to go through this.
 
You may want to do some more research on modifier-33. It ismy understanding that if the procedure qualifies, it should be appended to any CPT code that is not inherently a screening code. It doesn't mean that you can only use it when it becomes a therapeutic colon. 45378 is a diagnostic CPT code. I would code it as 45378-33/V76.51.

Bridgette Martin, LPN, CPC, CGIC
 
I find that quite a number of payors in our area want/expect the G0121 and G0105 codes for screening colonoscopies. I agree that it is a game they play but try those codes. I know from experience that BCBS will pay those codes.
 
For my local Blue Cross they have advised us that they regonized the modifier PT, which indicates that a colorectal cancer screening test was converted to a diagnostic test, this is from their provider notification letter. In addition, they have indicated that modifier 33 is to be appened to services whom meet the preventative services as recommended by the US Preventative Services Task Force (USPSTF). So based on this I would think you may need to append modifier 33..
 
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