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coderguy1939

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Patient with Blue Shield insurance had a screening colonoscopy (no pre-operative symptoms) and polyps were found and removed by snare 45385. DX codes used were V76.51 and 211.3. BS denied because patient did not have screening coverage. Can 211.3 be used as primary code if the purpose of the procedure was screening?
 
With Medicare you would still need to report the 'V' code as the primary dx, but there is "other carriers that require you to switch the diagnosis codes order". With BCBS I would go with the 211.3 as primary. The following note is from the Gastroenterology Coding Alert 2008 Vol. 10: " If the gastroenterologist find an adenomatous or other high risk histologic polyp during a screening, the patient is automatically at high risk for colon disease and therefore qualifies for more frequent screenings."

hope this helps,
 
Medicare wants the V code as #1 and 211.3 as #2 but you are only supposed to link #2 to the procedure. I believe in the case you have, you should code 211.3 #1 and V76.51 #2. That's how I would do it anyway...
 
I agree with the 211.3 1st.

As we all know Medicare has their own set of rules for colonscopies.

Unless I have something in written the carrier, I follow the ASC guidelines in our ICD9 book, Section 4 Letter O.

It states:

For Ambulatory surgery, code the diagnosis for which the surgery was performed. If the post operative diagnosis is known to be different from the preoperative diagnoisis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding since it is the most definitive.

I have this page printed, I send it to patients when they complain about how their insurance carrier processes their claims and I use it in appeals. Very handy documentation to have on hand :)

Hope this helps
Mary
 
This is where it pays to know your carrier guidelines and do verification of benefits prior to the patients arrival. Was a there an authorization on file from the providers office? If they had verified eligibilty they could have easily informed the patient of his coverage or lack thereof. Does anyone in your office do verification of benefits?
Now that you know the patients insurance does not cover screening and there was a problem found, it is now diagnostic, I would not even address the fact that it was scheduled as a screening. I would leave off the screeening code all together (because even if it is #2 on the claim form)they will still deny. Had the physician not found anything the patient would be liable. In this case you have a reason to resubmit the claim and if they deny you have a great case for appeal.
 
Thank you all for your input. I generally do follow the ICD9 guidelines, Mary, but there are so many peculiarities that seem to be connected with colonoscopies. Carriers (other than Mcare) generally want the v code first if the patient has screening benefits and often pay at 100% with that DX. I don't know if this procedure was pre-authorized, but I believe what happened in this particular situation is that the facility was not contracted with BS so the patient was out of network. So what I really want to know is if it is legit to code 211.3 first if the original intent was to utilize a screening benefit? Thanks.
 
yes it is legit :) 211.3 first then the V76.51

I know there are sooooo many different carrier variances but you will find very seldom that it is an actual carrier "guideline" (other than MCR and very few others). Bottom line is make sure you have the guideline "in writing" if they want you to go against the normal coding guidelines. Most of the time you will find that it is actually "patient benefit" driven. I can't begin to tell you how many times I have had a patient call and say "My insurance company said you coded it WRONG". NOT!! Ughhh I'm still trying to figure out why such a simple procedure is so difficult to get paid!!
 
new colonoscopy question

Are there any CPT codes for the indication that the physician went further than the ileum? For a diagnosis such as anemia? Thank you. Diana
:confused:
 
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