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Lyn123

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Can an op report contain both v76.51 and v12.72? We are having many patients come in for "screenings" on the schedule and when the report comes thru for billing, they have only v12.72 as the indication on the report. Some commercial carriers when the procedure is billed with the v12.72 charges co-insurance. What I wonder is if the report stated both codes, v76.51 and v12.72, if the patient would be under the ACA and get different benefits applied to the procedure by the insurance? Because the patient thinks, screening, screening, screening....Patient's train of thought is... I came in because it was time for a screening due to my age, and I happen to have history of polyps. Why isnt it "just a screening?, and why do I have to pay towards it."
 
HX Polyps

HX has been established that they have/had a polyp and pt comes back in for follow up on their history of polyps or has a benign/malig polyp removed. This is no longer a screening. It is a follow up... then code the follow up "other surgery" and the condition code (211.3 or HX) always go with local intermediary or insurance carrier rules.
 
So what I am understanding from the reply is that any patient whom has a hx of a polyp you would code as a surviellance / follow up exam V67.05 regardless if MD is stating diagnosis of screening for colorectal cancer and it has been a number of years since a polyp has been removed? Are you saying that this applies even if a polyp is discovered? I have just come across this and I do not have a comfort level that I agree. I appreciate further input on this. In my specific case patient presents to PMD whom recommends screening colo as a provisional diagnosis. Patient has a history of a very small hyperplastic polyp being removed 7 years prior by another MD. history of polyp is documented within H&P and on op note. Polyp is discovered and removed path indicates hyperplastic. How do you feel this should be coded? Not medicare commercial insurance coverage with screening criteria in place and carrier recognizes 33 modifier.
 
It is still a screening. In this case you don't need a modifier. Unless you are billing with a 45378 then you would use the 33.

If your payor accepts the G codes and you have it in your contract you can use the G0105 with the V12.72.

Otherwise, 45378, 33 modifier and then the V12.72 for a dx.

Because it is preventative. You are screening to see if the pt currently has a malignancy in his/her lower intestine.

V12.72 only shows they have a history of polyps. If they are not currently being treated for the polyps and it falls within the accepted time allowed, it is a screening.

I should ask, was anything found during the screening? If so, here's an example:

45385, mod 33, dx=v12.72, 211.3, 562.10
 
According to coding guidelines in the front of your ICD-9 book it states that "personal hx codes explain a patient's past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring." It also states that personal history codes can be used with follow -up codes and family hx codes can be used with screening codes. Because of how it is stated, I code personal hx as V12.72. I do not add screening since it states that it can not be used with personal hx codes. This is just how we handle this since we have documentation to back up how we code these scenarios.
 
I do agree that history of colon polyps should be considered high risk screening but not all commercial carriers recognize the G0105. As said on other threads and posts, it would be so much easier if everyone did it like Medicare.
 
I do not feel comfortable with putting V76.51 and V12.72 together since it states in coding guidelines that screening and personal hx codes cannot be used together. It states that family hx can be used with screening but not personal history. I would love to hear how someone else interprets these guidelines. I think they are pretty clear.
 
Susie,

I see what you're saying but you can read it a couple ways I guess.

According to the ICD-CM Guidlines, page 22:

"personal history codes may be used in conjunction with follow up codes."

It doesn't say you can't use them with screening codes.

If you look under screening it says you should use the "screening V code(V76.51 in this case) if that is what was planned".

So if the docotr tells you they need to do a colon screening because of history of polyps, in my opinion, you would use the V76.51 code first because that is what is planned and then the V12.72 because that is why it is planned. That is only if you do not use the G codes though.

Now if the payor accepts the G codes, even better. Then I would say G0105 with the
V12.72. Because the G code is the inherent screening code.

Also, maybe I'm missing it but where does it state you can't use V12.72 and a screening code together? I've read and re-read page 22 and the 2 sections regarding this discussion, section 4 and 5 and can't find that anywhere. Thanks!!
 
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Debra,

Are you asking me that?

If so here it is:

Also from pg 22 of the coding guidelines:

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

So again, you can read this different ways too.

How can you show the procedure was supposed to be a screening but converted to diagnostic with a V12.72 w/o using the V76.51? Sure, some payors will process correctly but not enough do.

Also, on page 29 section IV, part A subsection 1 (outpatient surgery):
"code the reason for the surgery as the first listed diagnosis"

Well the reason for the surgery is screening colonoscopy. You cannot show that it is supposed to be a screening using 45378 (or other diagnostic codes) by using V12.72. That only states the pt has a history of polyps, it's a secondary dx to why the procedure is being done.

Put it this way, a pt comes in for a screening and you use 45378 but they have no history, what dx would you use? V76.51 (which does not specify asymptomatic or otherwise, it only states Screening for malignant neoplasm, colon).

Ok, now another pt comes in for a screening but has a history of polyps. 45378, V76.51 and V12.72.

Once again for the first pt I would use G0121 and the V76.51.

For the 2nd pt I wouls use G0105 and V12.72.

But that's because the reason for the procedure is noted in the CPT itself for the G codes. It is not noted in the 45378 or diagnostic codes thereafter.
 
When a patient comes in for a colonoscopy for history of polyps that is the reason they are having the colonoscopy. They wouldn't be coming back after 2- 5 years if it was screening. They would be coming back in ten years. I think as stated previously - insurance companies just need to follow Medicare on this one. It would be so much easier!
 
What is a G0105? A high risk screening. And the timeline for that would be 2-5 years. It is still a screening. What makes it a high risk screening? The V12.72. It's still a screening.

So I go back to the use of a diagnsotic CPT 45378. V12.72 can be used with 789.00 to show part of medical decision making but V76.51 cannot because then it wouldn't be a screening.

V12.72 does not show anything about screening only that the pt has a history of something.

The only way to show screening (w/o using the G codes that is) is to use a screening V code and those are V28 and then V73-V82 codes. Note that V12.72 does not fall under that category.

I'm not saying you have to I'm saying you can and it does not break any coding law or ethic or moral and it shows the payor what was done and why it was done and lets them process the claim the correct way. The reason it was done with 2-5 years was a screening for malignant neoplasm with high risk indications. V76.51 (screening for malignant neoplasm) and V12.72 (hx of polyps, high risk indication).

Tomato/tomahto-you choose I guess.

But ask yourself, we use a PT modifier now for Medicare to show that it was indeed a screening converted even with the V76.51. And now the commercial payors are using (some) the 33 modifier to accurately show a screening.

So why would they use those? (Other than the fact they want to create more stringent guidelines for pt's) So they can process the claims correctly because the V12.72 doesn't accurately tell them it's a screening to start with and we've all begged them to do it correctly.
 
coachlang3 said:
Debra,

Are you asking me that?

If so here it is:

Also from pg 22 of the coding guidelines:

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

So again, you can read this different ways too.
How can you show the procedure was supposed to be a screening but converted to diagnostic with a V12.72 w/o using the V76.51? Sure, some payors will process correctly but not enough do.
4
Also, on page 29 section IV, part A subsection 1 (outpatient surgery):
"code the reason for the surgery as the first listed diagnosis"

Well the reason for the surgery is screening colonoscopy. You cannot show that it is supposed to be a screening using 45378 (or other diagnostic codes) by using V12.72. That only states the pt has a history of polyps, it's a secondary dx to why the procedure is being done.

Put it this way, a pt comes in for a screening and you use 45378 but they have no history, what dx would you use? V76.51 (which does not specify asymptomatic or otherwise, it only states Screening for malignant neoplasm, colon).

Ok, now another pt comes in for a screening but has a history of polyps. 45378, V76.51 and V12.72.

Once again for the first pt I would use G0121 and the V76.51.

For the 2nd pt I wouls use G0105 and V12.72.

But that's because the reason for the procedure is noted in the CPT itself for the G codes. It is not noted in the 45378 or diagnostic codes thereafter.
Click to expand...

So sorry i used the wrong quote! I am in total agreement with you. I was wanting to ask the poster that stated the guidelines stated you cannot code personal hx and screening together to please show where that is stated. I read the same thingyou read andi apologize for the miss quote.
 
No problem there. The way I put it, after I re-read, I wanted to ask myself where I got it, lol.

The whole problem here is, really, semantics on our part but total confusion created by commercial payors.

We see we can use V76.51 to show it was screening and that's ok. Should we be able to use V12.72? Yes. Medicare shows us we can. But they(commercial payors) won't process it as a screening thereby messing with the pt's benefits. Now, I won't change a code or do fraudulent billing, but if we can code it/bill it to show it was supposed to fall under the pt's screening benefits and the finding was due to the screening we should. It's not illegal, immoral or even unethical.

I have had payors tell us and put it in writing via email that for them to process it as a screening or screening w/findings, ala Medicare, we have to put the V76.51 as the lead dx.

It really is the commercial payors just trying to find any and every loophole so they don't have to pay.

Maybe it's why I love Pixar's The Incredibles so much. Mr. Incredible really gives it to that loud mouthed, ignorant insurance fellow, lol.
 
Debra - in the coding guidelines in the front of the ICD-9 book under history is where I got my info regarding personal hx and family hx. It states family hx can be coded with screening and personal hx can be coded with followup. I guess the fact that the don't state that personal hx can be coded with screening is what bothers me but they definitely state that for family hx. Coach - I just watched the Incredibles the other night with my daughter for 100th time it seems - love that movie! You gave me a laugh this morning - Thanks!
 
scorrado said:
Debra - in the coding guidelines in the front of the ICD-9 book under history is where I got my info regarding personal hx and family hx. It states family hx can be coded with screening and personal hx can be coded with followup. I guess the fact that the don't state that personal hx can be coded with screening is what bothers me but they definitely state that for family hx. Coach - I just watched the Incredibles the other night with my daughter for 100th time it seems - love that movie! You gave me a laugh this morning - Thanks!
Click to expand...

But no where in the guidelines does it state that you can not code screening and person al history together. It is this very combination that indicates that a patient is at high risk and eligible for more frequent screening and it is not prohibited by guideline. Just because the guidelines do not indicated that a combination of codes can be used together does not automatically indicate that it is a prohibited combination. Therefore i respectfully disagree with your interpretation of the guidelines.
 
Here's how I see it a little more cleanyl maybe:

The reason the pt is having the procedure is for a screening.

The reason the pt is having the screening at this time interval is because they have either a personal history or a family history.

I was thinking about this overnight.

Why would Medicare start using the PT modifier when they already process the claims as screening if you use either the V76.51, V12.72, V18.51, V10.05 or V16.0?

Why would commercial payors start using the 33 modifier?

Because they want to make sure they are processing the claims as screening under the pt's screening benefits.

That means they are not processing them correctly if you use a diagnostic CPT. That's why UHC and the local BC have told us to use the V76.51 as the first diagnosis on our screening claims that convert. So they can process the claims according to the pt's screening benefits.

Because V12.72 does not show it's a screening. But the 33 modifier will as does the PT modifier.

But to another point now. With Medicare say you have a 45380, V76.51 and 211.3. Colon biopsy for an average risk screening with polyp findings. Why need the pt as you're already showing the screening? Because the PT modifier flips the switch on any procedure done that day.

I just attended a gastro coding and billing seminar. What I didn't know was if you have a
G0121 and a G0105 and say, a, 43239. You would put the PT modifier on the EGD CPT.

What?????

It's really only a switch for the Medicare computers to process the whole procedure visit under the screening benefit.

Weird huh?
 
Interestingly, some commercial payers (specifically UHC) state in their guidelines for colonoscopy that if a patient has had a previous polyp removed it is no longer considered a 'routine screening' and therefore will apply to the patients medical benefits (deductible and co-insurance) because the patient is then recommended to have the colonoscopy at increased intervals.

So, with UHC patients their insurance tells them that if they have a personal hx of polyps is ISN'T a routine screening. For these patients we code V12.72 as the primary diagnosis and don't add V76.51. When there is patient push back on this, I send them a copy of the UHC document that states the policy and then refer the patient back to the insurance to dispute it further.
 
I will have an answer for this next week. At least as far as Medicare Florida is concerned.
I submitted around 400 visits in late October coded as V76.51 as the primary dx w/ various personal and family hx V-codes as secondaries. We dropped them on the 4th of November so hopefully we will know next week one way or the other.
This debate rages through my office every two to three weeks.
 
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Several months ago our office got a fax from Blue Cross of North Carolina stating that if the patient had a history of colon polyps (or any other history that would lead to needing a colon check) as the main reason for a colonoscopy that we should be billing those with the screening diagnosis code primary.:eek:
For further clarification I actually spoke with someone in their main office who is in charge of this change. She told me that if there was not a current sign or symptom that all colonoscopies would be considered screenings.
I even used a couple of examples that seemed far-fetched to me like a history of colon polyps, history of colon cancer, history of breast cancer (for a patient to be screened earlier than the currently accepted age), family history of colon polyps, family history of colon cancer, etc. And she said screening, all of those reasons and any others that are not current symptoms, are screenings from now on.
This has been a big debate in our office and obviously many others for quite some time. I actually like knowing how they want it. This has also helped cut down on angry patient calls when they get their bills because many family practice doctors will send them over for screenings because they have a history of polyps or colon cancer and they had no current symptoms and they were having to pay alot out of pocket for having a colonoscopy done.
Since late August I have been coding my Medicare and Medicaid claims this way as well. So far they all seem to be paying the way they should.:eek:
 
Exactly Grintwig. That's what I had said earlier that BC of NC and UHC have told us.

Now Medicare or Medicaid I wouldn't worry about those.

Medicare as long as you use the correct G code (if there are no findings) you can use the history of codes just fine. And if there are findings just plop the 33 modifier and you're still fine.

For Medicaid of NC, I'm not sure they care either way on the order of the dx, but they don't want G codes.
 
I should have said that I only use the G codes for Medicare;)
We have never really had a problem with Medicare or Medicaid in regards to the screenings. Medicare will not pay for the set-up visit but that is common knowledge.
North Carolina Medicaid does not want to pay for anything most of the time but that goes for all procedures:eek:
It seems to me like most of the commercial payers at least in my area (or with subscribers in my area) all seem to be following the same policy as BC of NC.:D
 
Screening Vs. Diagnostic

My physicians use an out patient facitility to do all of our procedures. This facility is responsible for all its billing. Over a year ago they changed their coding procedures. They decided to start coding all asymptomatic colonoscopies as screening using the V76.51 as the primary code and V12.72 or the findings as the secondary code. After some research with our commerical carriers I decided I would also change my coding policy. It is working great. Now due to change over in the coding staff the facility is once again changing its policy. The policy now is if a patient has ever had a polyp or are considered high risk they will not code the procedure with V76.51. I would love to simply continue to code all my procedures the way I do now but then my patients get stuck with huge hospital bills and that is not fair to them. Does anyone have any suggestions or better yet some guidelines I can print showing that a patient can indeed be considered high risk and still qualify for a V76.51?
 
I contacted UHC of GA, BCBS of GA, Cigna, and Humana and pateints with V12.72 are not to be coded with V76.51 primary because of the shortened interval of the screenings is considered surveillance, not screening. These patients are having their colonoscopies every 2-5 years instead of 10. If you read these carriers UM guidlines they state that patients with a history of polyps will be considered surveillance and processed under med necc benefits instead of screening. There is actually several notes in the Affordable Care Act (read deep and click on the links) regarding colonoscopy screenings stating that patients with a personal history of cancer and/or adenomatous polyps are not covered as screenings.

Also, ICD-9 guidelines state that family history codes are used with screening codes and that personal history codes are used with aftercare codes. ICD-9 is basically stating not to use V76.51 with V12.72. You can use V76.51 with V16.0.

I would make sure the carriers give you something in writing regarding using V76.51 primary with V12.72 secondary. I have seen audits where the carrier reprocesses it as high risk with V12.72 primary, forcing money back to the carrier and pt resp.

We have several 2 forms we give patients educating them prior to the procedure. They can be found on our website at www.atlantacolon.com. The first is under "Colonoscopy: What You Need to Know" and the second is under patient forms under "Colonoscopy Notification Form."

I fight with facilities, physicians, and patients all the time to get it right. I provide articles, carrier guidelines, etc to support coding. Eductaion is the best method.

Thanks for letting me add my two cents!
Anna Barnes, CPC, CEMC
 
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