Wiki I am being told to code colonoscopies a certain way -- HELP

[Jenannurb]

I work for a company that is part of a larger corporation.
All of our billing/coding directives come from this larger corporation.

I am being told that ALL colonoscopies are to be billed out using diagnosis Z12.11 as the primary diagnosis, regardless of whether it is a screen or a surveillance for "history of" or "family history of"
Now if we see a Medicare patient with a h/s polyps, I code out G0105 with Z86.010; of course any work done and I change the code to reflect procedure and append a modifier PT.

Ideas? thoughts? suggestions?




(Diagnostic colonoscopies are not an issue-they arent handing out any directives)

 

[Janelle926]

This would be news to me. I'm curious to see other peoples thoughts. Things change so often, but i would have to say that is incorrect.....

 

[williafm]

We use the G codes for all carriers but only if the indication for the colonoscopy is screening and that is all that was done. If the indication is for history of polyps then we do NOT use the screening code but rather the regular cpt code which is usually 45378 with the history of polyps dx. They really need to come out with a better system for these. pts believe they are always free and their ins would pay for it if the drs office would just " code it right". The ins companies tell the pts this as well.

 

[GastroGal]

a screening is a service performed in the absence of any signs or symptoms, (Z12.11) once the patient has a diagnosis of polyps follow up colonoscopies should be coded as surveillance(Z86.010) not screening for medicare and commercial insurances also on the commercial insurances you would attach a modifier 33. On the family history we would code G0105 and z80.0 or z83.71 for medicare and all other commercial insurances we use screening code as primary (Z12.11) and the family history would be secondary.

 

[thomas7331]

I'm not well versed in the payer requirements well for these procedures, but I can understand the reasoning in what they're saying from a medical perspective. As I understand it, a history of polyps and relevant family history are factors that are used to determine the frequency of screening which is recommended. But in the absence of signs or symptoms of disease, the procedure is still a screening, even with a history. 'Surveillance' is something that is done to monitor for recurrence of a disease or malignancy. Colon polyps are generally benign growths that are a risk factor but are not active disease - they do not necessary require treatment but are removed as a preventive measure.

 

[Jenannurb]

We use the G codes for all carriers but only if the indication for the colonoscopy is screening and that is all that was done. If the indication is for history of polyps then we do NOT use the screening code but rather the regular cpt code which is usually 45378 with the history of polyps dx. They really need to come out with a better system for these. pts believe they are always free and their ins would pay for it if the drs office would just " code it right". The ins companies tell the pts this as well.

You use the G codes for all of the carriers?
I always thought that the G codes were specific to Medicare. Do the commercials just convert the codes in their systems? Is the reimbursement the same?
Anyone else do this?

 

[Jenannurb]

I'm not well versed in the payer requirements well for these procedures, but I can understand the reasoning in what they're saying from a medical perspective. As I understand it, a history of polyps and relevant family history are factors that are used to determine the frequency of screening which is recommended. But in the absence of signs or symptoms of disease, the procedure is still a screening, even with a history. 'Surveillance' is something that is done to monitor for recurrence of a disease or malignancy. Colon polyps are generally benign growths that are a risk factor but are not active disease - they do not necessary require treatment but are removed as a preventive measure.

Thomas, I too can see that point. It is made more difficult because some insurances recognized the history of polyps code as a preventative service while others don't.
I wish that there were CPT codes that are designated for surveillance vs screening. (like mammography codes are)

 

[Jenannurb]

a screening is a service performed in the absence of any signs or symptoms, (Z12.11) once the patient has a diagnosis of polyps follow up colonoscopies should be coded as surveillance(Z86.010) not screening for medicare and commercial insurances also on the commercial insurances you would attach a modifier 33. On the family history we would code G0105 and z80.0 or z83.71 for medicare and all other commercial insurances we use screening code as primary (Z12.11) and the family history would be secondary.

My point exactly..
I had been doing just that; but now I am being directed to use the Z12.11 for all of them with the family/personal history codes behind it.

 

[CodingKing]

You use the G codes for all of the carriers?
I always thought that the G codes were specific to Medicare. Do the commercials just convert the codes in their systems? Is the reimbursement the same?
Anyone else do this?

If the commercial payer follows Medicare guidelines you should be using G codes when appropriate. Many cases the associated CPT is a RBRVS status I and will reject.