Wiki screening colons turned medical

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kerileigh

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i have a patient who presented for a screening colon. dr performed colon and found a polyp which was removed. I coded dx.1)v76.51, 2)v18.51, 3)211.3
procedure 45380 pointed with dx.3)211.3. The patient has a wellness benefit for preventive colon exams at 100%, but the ins co. did not pay it that way since the procedure code was linked to 211.3. Anyone with any suggestions, should i have linked all the dx's to the procedure???? Thanks for your help
 
I agree with Debra (even though we have disagreed on this in the past I have found she is correct - my apologies Debra!). I would code 45380 V76.51, 211.3, V18.51. For Medicare you would code 45380 V76.51, 211.3, V18.51 and only point to 211.3. Medicare is the only carrier I am aware of that will pay screening to diagnostic this way.
 
i hear ya on the 100% coverage, we are dealing with this every day. I am so tired of these companies dictating what procedure they will pay or not. i have been coding gi for 3 years and im tired of this lol. we have one facility that the surgeon likes to do both, upper and lower gi procedures, in anesthesia the higher value is chosen for the procedure and if the pt has 100% coverage for the colon and wasnt billed, i then have to call the facility ask how they billed and its just a big big mess.

My question is: how do you explain to a patient if they owe something and call and complain stating if we would have billed this as a screening the ins will pay... what if thats not the case and it turns to medical and they do owe? its more frustrating every day :(

any suggestions are greatly appreciated

i know weve all discussed this subject many many times, its just a topic that always needs to be discussed :)
 
I used to work in insurance and the way I've always explained the benefits to the members was that it's a screening until the doctor finds something and removes it then it's coded as a surgery(so their surgery benefits will apply which often means deductible and coinsurance). This is the best way I've found to explain this to them. It's short and to the point and the members have always been ok with that explanation.
 
i try that but the patient does not agree and fight/argue with my staff. im to the point that the surgeon did a removal, so the patient should take that up with the surgeon, not the anesthesia. i hate that we have to change these codes just so a patient doesnt have to pay. i do not agree with this at all. over the past few weeks weve had to send so many appeals/par forms to insurance companies asking them to reconsider the charge as a screening.

i have another question as well... what if the pt has a family history and thats the reason why they are coming in for the colon, not just for the screening. (V76.51) would i bill it this way: V76.51, V18.51---45378--linking this code to the 2nd diag?

thanks
 
Even with a family history, you would still be screening the patient. Code 45378 with dx #1 V76.51 and dx #2 V16.0 (for family hx of colon ca) or V18.51 (for family hx of colon polyps). Both codes would be linked to the procedure in the order above.
 
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