Wiki Colonoscopy Screening vs Diagnostic

[carsosa]

I am a new coder in GI. I was kind of put in this position with out any training what so ever!
I have 2 patients that came in to our facility the first patient was coded with CPT 45378 along with ICD-9 codes (in this order) V76.51, V16.0, 569.89, 455.0, and 569.3. The patient just called me and said her insurance (B/C B/S) denied stating that this should have been billed as Diagnostic and not a screening as patient has a family history and patient is under age 50.
Does anyone know what codes should be used? Nothing was done during the Colonoscopy as far as removing polyps or anything.

2nd patient...coded with CPT G0105 along with ICD-9 codes V76.51, 455.0, 455.3, 455.9, V16.0, and V58.69. Patient is under 40 and has family history as well. Blue Cross Federal denied for non-cov Diagnosis coding. Nothing was found during the Colonoscopy on this one either. What codes should be used for billing?

I sure do hope someone understands my questions as I could sure use some help.
Thanks,
Shawna

 

[hbeard]

For the 1st patient, the 569.3 for rectal bleeding is a symptom. If the patient was symptomatic, they should not be billed as a screening. So bill 569.3 and 569.89 for the intestinal lesion with the 45378. Removing the rectal bleeding fractor and basing this as a screening scenario, for BCBS, I would code the V16.0 first and V76.51 second with 45378. but again, if the reason for the colonoscopy was the rectal bleeding, the symptoms trump the screening codes.

For the second patient, G codes are only used for Medicare and Medicare supplement plans so 45378 is the correct code. Again with the screening code and the family history code, V16.0 would be first and V76.51 would be second.

Regarding screening for patients with family history of colon cancer, must insurances will cover the screening 10 years prior to the age of the first degree family relative(parents, siblings,children) was diagnosed. So patient who's mother had colon cancer at 50 should have a screening at 40. Patients also need to be honest about the their symptoms, symptoms=not a screening. Screening codes mean no prior history of colon ca, colon polyps.

 

[melwalters]

In Michigan we have been instructed by Blue Cross Blue Shield to bill them the same as we bill Medicare. So we bill G0121 for screening and G0105 for high risk screening.

In the first patient example I would bill (in Michigan) 45378 with 569.3, 569.89, V16.0 because rectal bleeding is a symptom.

In the second patient example I would bill (in Michigan) G0105 with V16.0 as the primary diagnosis. You cannot bill G0105 with V76.51 as the primary diagnosis as G0105 is high risk and V76.51 is used for a patient with no known symptoms, personal history of colon polyp or cancer, and no family history of colon polyps or cancer.