Wiki Surveillance/Personal0 - I do billing/coding

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egraham1827

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I do billing/coding for the physician and need some clarification on the surveillance guidelines. When a patient has a colonoscopy initiated for personal hx of polyps I code this as V12.72 primary with any findings secondary and use the appropriate CPT code (G0105, 45378, 45380, etc.) However, the hospital has been using V67.9 (unspecified follow-up examination) as the PRIMARY dx on their claims with V12.72 (personal hx) as secondary. Their claims are processed under the yearly deductible for Anthem (or other commercials) patients, and our claims are processed under 100% screening benefits causing problems and confusion for the patients.

Referencing the October & December issues of Coding Edge has only increased my confusion. The December article states that for a partient returning for personal hx is considered suveillance rather than screening. This makes sense to me; however, reading further along states that V67.9 is actually the appropriate primary dx for personal hx, with V12.72 as secondary? Why does it make sense from a coding perspective to use an unspecified exam code as primary dx for a patient who is undergoing a procedure for a SPECIFIED problem- personal hx? The article indicates that V67.9 is to be used when the patient is in the 10 year window from the first dx of polyps (under the Affordable Care Act), so therefore saying that V67.9 is a time period code, but the actual definition of the code says nothing of this...

The article goes on to say that "some payers may not accpet a nonspecific dx code as primary, for these payers use V12.72 primary and V67.9 secondary". Of course they don't accept an unspecified code as primary and that's not even why the procedure is being initiated. Also, the ICD-9 book clearly states under catergory V67 that "follow up codes may be used in conjunction with history codes to provide the full picture (ok, that makes sense), but the followup code is sequenced FIRST followed by the history code (this does not make sense to me when applied to colonscopy billing/coding...) So even for payers that don't accept nonspecific codes primary we still cannot put V12.72 primary with V67.9 secondary as clearly stated in the ICD-9 book. Therefore claims are being processed under diagnostic benefits and not screening which is causing patients to say they will no longer undergo this procedure knowing that they will be paying a large sum out of pocket even though they have a hx and no current problems.

I just really need someone to explain to me (with facts and proof, not opinion!) why V67.9 is used as primary even though it is a completely nonspecific code and in no way relates to colonoscopies initiated for personal hx in the definition itself. Under the Affordable Care Act a lot has changed for these procedures and I need to know that I'm coding and billing accurately under the guidelines to receive proper payment and prevent auditing. Thank you so much for taking the time to read this and any help/suggestions/info is greatly apprectiated!!!
 
To be honest, I have no idea why the hospital would bill with V67.09 as primary and V12.72 as secondary. The V12.72 is an exact dx code that states that patient has a hx of colon polyps. If it is time for patient to get a screening (high risk) this is the correct code to use. The 100% coverage should kick in on both sides, professional and facility. If a patient had a screening colonoscopy a month earlier and the physician wants to follow up on some or other finding, the follow-up code V67.09 is appropriate.

I think you are doing it correctly.
 
I believe there is a n AHA coding clinic on this that does stipulate to use the V67.xx code first listed. It is a follow up code and follow up is defined as a surveilance exam. There is no time frame for a follow up; it can still be a follow up months or even years later.
 
I do coding for a gastroenterology clinic and completely understand this frustration. I have extensively researched this exact topic. The AGA website has a very helpful article entitled: "Screening Versus Diagnostic Colonoscopy" dated 1/4/2011.
I have also researched the specific payer policies on their individual websites and have discovered that, in my state Medicare (Noridian) is the only payer who will waive ded/coins for surveillance colonoscopies. All other payers (BCBS, Aetna, Cigna, UHC, Coventry, etc.) consider surveillance to be following up on an established problem and therefore applied to the patient's ded/coins. Patient's are not always aware of this and are very frustrated when they get a bill they weren't expecting. Making the problem worse is that sometimes the hospital and physician coding isn't done the same and one gets covered at 100% and one doesn't.

Most payers seem to be in agreement that if a procedure begins as a preventive screening, the primary dx code should be the screening dx and anything found would be secondary. (for example: V76.51, 211.3). Most waive ded/coins whether or not there is a finding on exam. After that they all split into different viewpoints.

Wellmark BCBS, for example, has a helpful guide for how they want each scenario coded. It is in their Outatient Services Guide to Billing Facility Services July 2012. They want V67.00 as the primary diagnosis followed by V12.72, V10.05, etc IF a colonoscopy is performed due to a personal history and NOTHING further is found.
If, however, more cancer or polyps, are found they want the diagnosis codes sequenced as the finding primary (211.3, 153.x, etc.) followed by the personal history code (V12.72,153.x, etc,)

We have held education Q&A sessions with the physicians, nurses, coders, both hospital and physician side and have been very carefully following the recommendations of the AGA as well as the specific payer policies and we seem to be working our way through the quagmire.

We have also developed a patient awareness sheet that we go through with each patient explaining the difference between preventive screening procedures and diagnostic procedures and the impact on what they may be asked to pay.

We have heard way too many times from patients that their insurance company told them "it was coded wrong" when in fact, that really wasn't the case at all.

It really comes down to how your payer wants these submitted.

Hope that helps some.....
 
67.09

If you go to the ngsmedicare.com web site, Part B to the left click on medicare LCD's. LCD # L26404 (Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy it does tell you about use of the v67.09. It is basically a code used for Medicare Patients be it straight Medicare or Medicare advantage plans.
Hope this helps
 
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