Wiki Coding Colon Screenings for Commercial Payors

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bluemoon1

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A patient with a personal history of colon polyps (V12.72) but NO current symptoms comes in for a colonoscopy. During the colonoscopy a polyp is found. Would it be coded as a screening for commercial payors? Specifically, would it be coded as V76.51, 211.3
 
I agree with the codes suggested , but remember the diagnosis codes have no bearing on your contract, since this is the patient's diagnosis, the provider is the one that determines this and we code accordingly, the contract with the carrier can in no way affect our choice of dx code nor the order listed.
 
We code 211.3 and V12.72. It does state in the guidelines in the front of your ICD-9 book under history that personal history codes can be used with followup codes and family hx codes can be used with screening codes. Since it does not state that personal history can be used with screening codes I do not use screening codes with V12.72. Hope this helps!
 
Actually our local BCBS and UHC reps have told us and put it in writing they want the V76.51dx code put on all charges or they will not consider it a screening (high risk or otherwise). Now, the 33 modifier should have taken care of it, but we are getting denials back from those carriers about it's use.

Why o why can't payors just follow Medicare, even if it is a different modifier. :confused:

PS And the expalnation for my use of payor contract is the use of a G-code. I forgot to state that, lol.
 
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I also went into the guidelines and found this

"A screening code may be the first listed code if the reason for the visit is specifically the screening exam."

"Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis."

"The V code indicates that a screening exam is planned."

"The screening V code categories:

V28
V73-V82"

So I still propose you can use the V76.51 as the first dx to show a screening was planned. The V12.72 is not a screening code it is a history code and the reason you are doing a screening. So unless you are using a G code, the CPT won't show it as a planned screening. Now if the sole reason you were doing a 45378 was due to the personal history than sure, you'd use the V12.72. But if you were planning on doing a screening because of the personal history? V76.51. Semantics? Sure. :eek: But it works within the guidelines. :D

I still like the Medicare way though.:cool:

I also am really starting to like the use of the smilies, lol
 
Commercial screening

What if the patient doesn't have a history of polyps, and the procedure is a screening during which diverticulosis is found? For Medicare, we code the admitting and primary as V76.51, all other diagnoses are listed after this. For all other insurances, the admitting and primary remain V76.51 if nothing is found on the examination. If something is found, it becomes the primay diagnosis. Any input is appreciated.
 
Scatlot said:
What if the patient doesn't have a history of polyps, and the procedure is a screening during which diverticulosis is found? For Medicare, we code the admitting and primary as V76.51, all other diagnoses are listed after this. For all other insurances, the admitting and primary remain V76.51 if nothing is found on the examination. If something is found, it becomes the primay diagnosis. Any input is appreciated.
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The screening dx code remains first-listed regardless of the findings and this applies to all carriers not just Medicare. This is a diagnosis guideline not a payment guideline. The patient is asymptomatic and presents for screening, the finding is not expected and is incidental to the reason for the encounter therefore the encounter remains screening. Incidental findings are always listed secondary. The patient presented asymptomatic, you cannot indicate symptomatic after the fact. If the patient presents with a symptom say rectal bleeding and the finding then is diverticulitis then we can replace the symptom with the finding because you were specifically looking for the origin of the symptom and you found it. In a screening you have an asymptomatic patient for whom any findings are simple incidental to the presenting indication.
 
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I have been told that once a patient presents with a history of colon polyps their colonoscopies can never be a screening again. Agree or disagree?
 
Disagree.

Hence you have Medicare giving us the G0105 high risk screening code!!!

Just because you have a history of something doesn't mean you are currently having issues from it that need to be treated.

My opinion of course :D
 
Actually Ocean,

It would be, for Medicare,

V12.72, 211.3 (if the pt had a hx of polyps that is) with a PT modifier.

But for a commercial payor,

V76.51, 211.3, V12.72 (technically you can use the 33 modifier, but like I've said commercial payors are denying our claims with that mod)
 
Coach,
I am currently in the midst of a test of Medicare and Commercial in Fla to find out excatly what you stated above.
Last week I submitted about 400 claims to various carriers for an endo center in Fla with the history leading dx if present to see how they respond.
This has been an ongoing debate in my office.
I am of the mind that the hx not only identifies the procedure as a screening it also identifies (and should eliminate) frequency rejections.
I am only coding the anesthesia portion of the service so I have no other way to impart high risk.
 
Therein lies part of the problem. Proving high risk, especially for those under the age of 50, with out all the extra work to provide documentation.

I would like to be able to follow Medicare's guidlines for the commercial payors but it just has never been feasible. The intent of the procedure/visit is to screen for malignant neoplasms (ie colon cancer). Hence the fact they had any history whatsoever (family or personal) makes no difference as long as they are not currently being treated for that history. High risk is just an indicator for frequency or for age (ie 25y/o w/pers hx of polyps). Most payors don't like the G codes so you must use the diagnostic 45378 (or appropriate CPT). Now if you then code a V12.72 or V16.0 along with the 45378, the payor will generally see that as diagnostic instead of screening and will process it as such thereby skipping over the pt's screening benefits. Is that fair to the pt? To the billing physician who then has to make calls and use time to contact the payor to correct the error? It also withholds timely payment to the doctor and staff.

UHC and BCBS have both told the practice I work for to put the V76.51 as the first dx and then put findings and then history. That is so they see the screening and process it accordingly. It says to me they are too lazy to actually care and see all the dx's.

The whole problem was fixed by the creation of the 33 modifier but as I've said previously, every single claim we sent in, to every commercial payor, with the 33, was denied.

I'd be interested to see your test findings though.
 
In response to rcclary's post (above) - ever since the Affordable Care Act was passed, mandating coverage of 'screenings' without coinsurance or deductible, commercial payers have been changing their policies/benefits to limit the number of "screenings" they will have to cover - in case the Act doesn't get repealed.

Regarding colorectal cancer screenings, we're starting to see policies from commercial payers that specifically state that if a 'member' has a personal history of colon/rectal polyps, their colonoscopy is not considered a screening. (Scary...pretty soon you won't be able to get any preventive services unless you've never been to a doctor before.) So rcclary - you may have been looking at coverage and benefits from a commercial policy.

Medicare considers it a screening (high risk) if the patient has a personal history of polyps but the commercial payers are trying to shrink the number of procedures that they pay for under their 'screening' benefits.

Coach - I'm with you - I wish everyone was on the 'Medicare' page as far as coding for colonoscopies. It's easier when there's just one set of rules to follow.
 
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