Wiki Screening colonoscopy diagnosis coding for pathology procedure code 88305

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mpasternack@dahlchase.com

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Hello,
I have a question that our group has been going back and forth over for screening colonoscopies. We receive colonoscopy cases from Hospitals that bill out the technical portion of the charge and we bill out the professional portion of the 88305's - what diagnosis code would you use as the primary diagnosis code for our Pathology group??

1) the screening diagnosis code & then the finding diagnosis ?
2) the finding diagnosis & no screening code?
3) the findings diagnosis, with modifier 33?
4 the screening diagnosis, the finding diagnosis & modifier 33?

Thanks for any help :)
 
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I believe #2 is the most correct answer. A pathology service is never a screening in this context. A tissue sample would only be taken if there was an abnormality found during the colonoscopy, so it is only related to the findings, not to the screening. I don't know of any payer that would classify pathology services as part of a member's preventive care benefits.
 
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thomas7331 said:
I believe #2 is the most correct answer. A pathology service is never a screening in this context. A tissue sample would only be taken if there was an abnormality found during the colonoscopy, so it is only related to the findings, not to the screening. I don't know of any payer that would classify pathology services as part of a member's preventive care benefits.
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Thank You, That is what we have been doing but had some questions from staff who answer the phones and have to relay this answer to patients calling as to why. I was having a hard time to find written guidelines on diag. coding placement for pathology so we might have something to send if the patient wanted/asked for it as they have in the past.
Thanks again!
 
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With my experience with other commercial payers, for instance BCBS( MS ) , If the patient came in for a screening colonoscopy, the Z12.11( 33 modifier) is your primary dx and D12.__ . And in this order is the same way filing their pathology 88305.
 
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lcolborn said:
With my experience with other commercial payers, for instance BCBS( MS ) , If the patient came in for a screening colonoscopy, the Z12.11( 33 modifier) is your primary dx and D12.__ . And in this order is the same way filing their pathology 88305.
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I'm thinking what you are saying applies to "non-outpatient" settings?

There are three specific sections for ICD 10 Coding Guidelines that specify what to code as primary.

Section II is for non-outpatient settings

Section III is for additional dx in non-outpatient settings

Section IV is for outpatient coding and reporting . <<<< Clinical Pathology Lab would fit here.
Under Section IV. A. Selection of first-listed conditions. "In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. "

____________________________________________________________________________________________________________________________________________________________________________________________
In the above scenario the pathologist is the physician & his/her findings should be reported as the first listed diagnosis.

I saw a previous post from 2018 in this forum that I think is still appropriate to this thread.
Copied and Pasted:
"A pathologist is a physician, and therefore their final diagnosis and findings should be reported as the first-listed diagnosis. Although the intent of the colonoscopy was a screening, that code should be appended to the screening colonoscopy, not the pathologists' claim, since his tissue analysis shows a confirmation of a polyp. See AHA Coding Clinic 1Q2017.

The insurance company is telling the patient this because 1.) they aren't coders, and 2). their insured is upset because they are going to have deductible/co-insurance responsibility for the pathologist's bill, instead of a screening visit, which has no patient responsiblity. The payer is telling the patient that it was 'coded wrong', so that the payer won't have to take the heat for the patient being upset.

If I had a dollar for everyone of these scenarios that has crossed my desk since the ACA was implemented, I would be on a beach in Tahiti right now, sipping margaritas. It's a pain that the payers throw coders under the bus, when they don't even understand the rules.

We should not code for payment/coverage reasons."
 
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lcolborn said:
With my experience with other commercial payers, for instance BCBS( MS ) , If the patient came in for a screening colonoscopy, the Z12.11( 33 modifier) is your primary dx and D12.__ . And in this order is the same way filing their pathology 88305.
Click to expand...
We used to do this for outpatient procedures but recently BCBS are denying and we needed to remove Z12.11 as the primary diagnosis. Anybody else experiencing this?
 
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We just received a phone call from a patient that has a Cigna Allegiance plan - their insurance said that we should use the Z12.11 as primary on the pathology charge. We have never done that as was stated previously, pathology is a finding and would never be screening. I will be watching to see what they actually do with the corrected claim that was sent in.
 
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Hi Everyone,
From my past experience if the patient had symptom to warrant a colonoscopy..put that as first dx. So let us say the patient had fecal abnormalities dx R19.5 or bleeding K92 dx, then add Z12.11 or Z13.811 as last dx code. This dx. data should come from the doctor of course.

Versus if the patient is getting a Medicare funded annual colonoscopy screening without any problems or past problems use Z12.11 add modifier 33 on this CPT code. If the patient had past polyps now required new screening/check up again add a dx reason from doctor to check up R19.828 or K63.5 then Z12.11,or past history of polyps z86.010 as last dx. If the doctor discovers polyps per section of the colon use dx blocks D12, or locates dx K64 hemorrhoid or dx K59.09 intestinal disorders if warranted after the colon review process. I d add this first dx on claim then follow last Z12.11 dx..
I hope this is understandable and helps you.
Lady T
 
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Hi, you need to touch up on the ICD excludes notes. You may not use a "screening code" because it states in our book to sign for sign or symptom. Yeah, back in the day it was alright but now not. If the patient had fecal abnormalities it is diagnostic. You cannot share a diagnostic code with a screening code.

mconner001 This is not a screening code scenario. They want you to use the Z12.11 so the patient quits calling and complaining so they will fully pay it!! Yes the moment you "correct the invoice" to show it was a screening even otherwise it now "seems" alright when it isn't. Cigna isn't anyone's (or any coder or denial specialist favorite". Patient will be responsible if you coded it correctly.​

 
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Is there verbiage somewhere to support this? I agree that, once a specimen is sent to the pathology lab for testing, it is diagnostic - not screening. However, insurance companies and clients both tell the patients that the lab "coded it wrong" when they get a bill. It would be helpful to have something concrete to support why we are coding as diagnostic rather than screening. Also - is there ever an instance where the pathology lab would put the screening code first?
 
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Hi Lynn877,
I am clearly not dying on this hill tonight on what is acceptable or not okay. You need to figure out each of your insurance providers requirements to accommodate each and every one of those policies individually because it is completely CLEAR from prior statements that their policy's requirement's differ (need screening code first or not). That I am baffled on (The GI doctor found something so I'm going to apply a screening code? Nope, no I'm all about the final interpretation form my pathology provider. I am a pathology coder and will code for the entire accession not the specimen. Unless I was told this FROM this made up accession off of the top of my head ~ I made up that that MNO Olympics from wherever stated they need a screening code before a diagnostic code. I am simply going to seriously code my pathologist's final interpretation all day long here. You need two different billers here (one to explain the denials not just professional but government). You can create rules on this to ensure you are billing it correctly.
Thank you for listening and have a wonderful evening,
Dana
 
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I have always been told that once your pathologist has found something with the colonoscopy it ceases to be a screening. I have just been coding what my pathologist found. Insurance companies are not coders and they will tell the pts what they want to hear ie "they coded it wrong". Pushes the problem back to us. It is tough talking with the patients on this point but it what I stand by. If audited they will go by my report and nothing else.
 
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Good evening RobynKing,
I have been an advocate in pathology for quite some time. You are accurate. You find a polyp, adenoma of cecum, polyp of rectum that you just code the pathologist's interpretation. There are numerous medical policies out there (AETNA, UHC, Cigna, among others out there). If it's a payer requirement to get the screening code on the claim, well you put those edits where they need to be or modifiers.
I'm in my pathology WQ coding and I sent an adenoma of cecum and accepted the charge.
It should hit another edit. So okay, I get to work another WQ because that insurance payor requires Z12.11 as another diagnosis code to meet medical necessity. Therefore, I touched this claim once and spend more time analyzing this. Therefore, I do some digging in their medical record and they have a history of adenomas in the colon. Or lets state because the patient is high risk screening because they have ulcerative colitis. This whole coding thing baffles me. When it transitioned from a screening to the surgeon found possibly something and there are multiple biopsies throughout the colon to find out that inflammation was identified. But Payors expect this, patients expect this. Some of those payor policies need to rest. Some of the patient's need to rest. The surgeon cannot screen for a medical condition they already have.
I have reviewed follow up for multiple types of colitis, CROHN's, so forth. It wasn't even a screening. It was a follow up. Figure out how to educate the patient's that this isn't covered. And Payor edits will be worked on backend.
Have a great evening,
Dana​

 
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