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Surveillance is V12.72 primary with appropriate procedure code. If no polyps found and no biospies taken then bill either 45378 or G0105. I usually try to bill G0105 even to commercial payers since most will accept this as a high risk surveillance. If a biopsy is taken or polyp removed still use V12.72 primary with 211.3 secondary and append either 33 or PT mod depending on your payers preference. I commented on the other post about the modifiers. Even doing it correctly can still result in patient balances depending on their plans under the Affordable Care Act. Educate your patients prior to the procedure; that form in the March article looks like it would be really helpful.
 
egraham1827 said:
Surveillance is V12.72 primary with appropriate procedure code. If no polyps found and no biospies taken then bill either 45378 or G0105. I usually try to bill G0105 even to commercial payers since most will accept this as a high risk surveillance. If a biopsy is taken or polyp removed still use V12.72 primary with 211.3 secondary and append either 33 or PT mod depending on your payers preference. I commented on the other post about the modifiers. Even doing it correctly can still result in patient balances depending on their plans under the Affordable Care Act. Educate your patients prior to the procedure; that form in the March article looks like it would be really helpful.
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The problem with the Cutting Edge article is that even though it clearly states the difference between a screening and a survillance colonoscopy, it does not address the use of modifier 33. The ACA followed recommendations by the USPSTF, and state that patients with a personal hx of polyps or cancer are not covered under a screening guidance, but a surveillance program. There is nothing in writing (that I can find), that states it is/ or is not okay to use the -33 modifier for surveillance colonoscopies. That modifier is what can allow a payers' edits to process the colon as "preventative". My concern lies with whether or not we have been inappropriately appending the 33 modifier to surveillance colonoscopies.
 
This is in the April Cutting Edge:

Screening-turned-diagnostic Colonoscopy,
Modifier 33, and Commercial Insurance

I read with interest Sarah W. Sebikari’s, MHA, CPC, article on coding
colorectal screening (“Consider All Factors when Coding Colonoscopies,”
October 2012, pages 26-28), and Kenneth D. Beckman’s, MD,
MBA, CPE, CPC, letter to the editor about personal history of colon polyps
(“Surveillance Colonoscopy Rules Differ from Pure Screenings,” December
2012, page 10). Thank you for both.
My question concerns patients with commercial insurance. When a patient
comes in for a colonoscopy with the diagnosis of personal history of colon
polyps, and if during this procedure a polyp is found, would it be appropriate
to list the diagnostic procedure code with modifier 33 Preventive services?
I ask because some commercial insurance companies list V12.72 Personal
history of colonic polyps under their preventive benefits.
Marci Klaubauf, CPC, MBS


"This is a complicated issue with many factors. The best advice is to look to
the carrier for guidance.
In many instances, commercial carriers will require modifier 33 and/or PT
Colorectal screening test converted to diagnostic test or other procedure to indicate
a procedure began as a preventive service, but resulted in a therapeutic
service (e.g., a screening colonoscopy resulted in a polypectomy). There
are several carriers, however, that do not recognize modifier PT and will instruct
you to use modifier 33 instead. There are also a few carriers who will
not recognize either modifier.
At my clinic, we have a list of our major carriers, noting their preference for
modifier 33 or PT use on a personal history diagnosis. Many commercial
carriers will not recognize V12.72 for a preventive service, and instead assign
this diagnosis for a surveillance (diagnostic) service, which would make
the use of either PT or 33 unnecessary. Medicare is the only insurer I am
aware of that processes surveillance and screening colonoscopies the same.
Let’s say, for example, the patient’s carrier is UnitedHealthcare® (UHC).
UHC’s modifier 33 policy is a great example of the direction most carriers
are going.
Per UHC’s policy, outlined in “Coverage Determination Guideline, Preventive
Care Services,” a coder should first determine whether the colonoscopy
is preventive (no symptoms, regular intervals, no personal history) or
diagnostic, which would include patients with a personal history of adenomatous
polyps who are undergoing surveillance at shortened intervals (five
versus 10 years). If the procedure starts out as preventive, and subsequently
converts to therapeutic due to a finding during the procedure, the coder
would use modifier 33.
The UHC policy states:
Modifier 33: UnitedHealthcare considers the procedures and
diagnostic codes and Claims Edit Criteria listed in the table below
in determining whether preventive care benefits apply. While
modifier 33 may be reported, it is not used in making preventive
care benefit determinations.
Fecal Occult Blood Testing, Sigmoidoscopy, or Colonoscopy:
Procedure Code(s):
Code Group 1: G0104, G0105, G0106, G0120, G0121, G0122,
G0328
Code Group 2: 44388, 44389, 44392, 44393, 44394, 45330,
45331, 45333, 45338, 45339, 45378, 45380, 45381, 45383,
45384, 45385, 82270, 82274, 88304, 88305
Diagnosis Code(s) (for Code Group 2): V16.0, V18.51, V18.59,
V70.0, V76.41, V76.50, V76.51
In other words, you would not use modifier 33 in this instance because
V12.72 is not a preventive diagnosis. Under UHC guidelines, this patient
would be undergoing a diagnostic (surveillance) procedure."
Anna Conlon Barnes, CPC, CEMC, CGSC
Director of Operations for Atlanta Colon and Rectal Surgery
 
Surveillance Colonoscopies

Can anyone tell me where to find info on surveillance colonoscopies per Medicare guidelines? Having trouble finding info on Medicare website. Thanks!!!!
 
My question is if V12.72 is surveillance then how can we use the G0105 which by definition states "Colon cancer SCREENING for high risk patients" if it is a clean colonoscopy?
 
The March article is confusing and seems to contradict itself to me. I've been looking for something to support it and can't. I found an article that totally says the opposite entitled "Consider all factors when coding Colonoscopies" here on AAPC's website. It is dated OCT 1 2012. In example 4 of this article the pt has a personal HX of polyps-V12.72 and a normal colonoscopy was performed with no findings and they code it: G0105 with DX's V76.51,V12.72. The rationale is : The pt is considered high risk per Medicare guidelines making G0105 the appropriate screening code. So my question is how did this change so drastically between OCT 2012 and March 2013 and where is the guidance to support it? I've read Medicares Processing Manual Chapter 18 chapter 60 and can find nothing that supports the March article. Medicare defines a pt with a personal hx of polyps as being high risk and will pay every 24 months for a screening per chapter 18 of the processing guide so why can't we use G0105 with V76.51 and use the secondary DX to explain why the pt is high risk? Totally confused as to where this new information on how to code it came from?
 
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From the way I see it (others might not agree) if you are inside of the time that Medicare gives you could use V67.09 and V12.72 and the CPT would be 45378. That to me would show surveillance (or follow up) of the polyps. You wouldn't use G0105 for surveillance, you would use it for CCS due to the history of polyps. Therefore G0105 and V12.72 would be used for CCS when you are going by Medicare time guidelines.
 
I agree with EricaR--the key to billing appropriately and the problem this is such an issue is because the billing of surviellance colonoscopies is payer specific.

Part B newsletter is a great resource for billing Medicare colonoscopies appropriately. The bottom line is that Medicare (unlike some commercial payers) have stated that G0105 is for high risk screening and this is allowed for patient every 24 months with a high risk characteristic---including personal history of colon polyps. In this case, Medicare considers surviellance for hx of colon polyps as a high rish screening. Therefore appropriately billed with G0105-put simply this is Medicares definition and guidance on billing for pt with no symptoms other than hx of colon polyps. Of course, if a biopsy is done during a Medicare surveillance colonsocopy you would append either PT or 33 modifier (per Part B newsletter they will accept either).

Whereas, many commercial payers state a surviellance colonoscopy for hx of colon polyps would not be considered screening and therefore, not payable under the preventive benefits. While commercial payers are required to cover screening colonoscopy under the new healthcare guideline, there is not a specific requirement for surveillance colonoscopies-therefore, allowing them in essence to make their own guideline to billing surveillance (under preventive benefits or not). Leaving us to refer back to the payer policy for appropriate billing.

Whether we agree with their rationale or not, Medicare informs us to bill the G0105 when done for hx of colon polyps-allowed every 24 mths. The following is link provides the information for the characteristics considered "high risk" by Medicare.

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/SE0613.pdf
 
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