Wiki Surveillance versus Screening Colonoscopy

[NESmith]

I know that this has been discussed over and over again, but I need help once again. I have a patient that had a screening colonoscopy in April of 2004. A sessile polyp was found and removed. The patient was advised to return within 3 years for a repeat colonoscopy which he did not. Patient has now changed insurance and has returned for a colonoscopy. The colonoscopy was performed and billed as a diagnostic with Dx code V12.72 personal hx of polyps. Patient is now angery because he checked his benefits and was told if this was billed as a screening the insurance would pay at 100%. Patient wants the diagnostic colonoscopy changed to screening so his insurance will pay. I do not think this is correct, please give me your opinion. Thanks as always for your help.

 

[sleepycats]

I think if the patient had come back in three years like they were asked to and nothing was found, V67.09 would have been appropriate. If something were found, you wouldn't code V67.09; only the findings would be coded. Colonoscopy guidelines are usually 5 years for high risk and 10 years for those who don't qualify as high risk. As long as the patient didn't have any signs or symptoms (change in bowel habits, etc.), I think it should have been billed as a screening.

 

[rcclary]

The coders in my office and the coders in the hospital have been going back and forth on this issue. The coder in the hospital states that once you have a history of colon polyps you cannot have a screening again and V67.09 and V12.72 will have to be used. Does anyone have an opinion about this?

 

[capricew]

First of all,
the v codes are screening/surveillance codes.

Secondly,anytime a patient comes in for no other reason than to have a colonoscopy for screening/surveillance you bill the v code.

In regards to above scenario:
For medicare screening if nothing is found during the screening
you bill g0105, dx v12.72 as pt is high risk for previous history of polyps

but--if a polyp is found medicare states you have to bill it as such:
45385 (or appropriate cpt based on method of removal), dx v12.72, 211.3
medicare states that the v12.72 must be the first listed dx code on claim, but your diagnosis pointer must point to 211.3 only. This allows medicare to keep track of pt screening exams.

Third, commercial carriers have their own set of rules. In general, i bill them the same as i do medicare so that they can see on the claim that the patient came in for screening but the diagnosis pointer lists 211.3 first and then the v12.72.

I hope this helps,
caprice -- cpc

 

[capricew]

In addition,

not all commercial carriers recognize medicares g codes for screening colonoscopy.
If on the above patient, his insurance recognizes those codes, then i would bill the g0105, dx v12.72

if his ins does not recognize it, then you have to bill 45378, v12.72

regardless, his insurance should be able to tell by the diagnosis you billed that it was a screening/surveillance. Perhaps you should add dx
v76.51 as well to the claim


caprice--cpc