Wiki V Codes as Preventive Only

[NESmith]

Ok, Ii am not sure what to do. i have a patient who was seen by one of our GI providers due to Hx of Colon Polyps((V12.72) The documenation reads:
CC: Previous surgery of colon polyps
HPI:A 64 year old referred by PCP for screening colonoscopy. He had previous polpys removed in the past. his last colonoscopy was seven years agao and was normal. he previously had no lower GI complaints and denies a Family hixtory of colon cancer. He has had stents placed and is on plavix . He will chcek with his cariologist for clearance before stopping Plavix.
PSFH done
Updated Medication was done.
ROS Done
PE; Gen: A pleasant white male who is overweight. No acute distress.
Vitals done
EYE: There are no jaundice or arcus senilis. My examination revealed good hygiene on teeth. No infiltrates.
NECK: Supple. Thyroid gland is not enlarged. There are no bruits.
Chest: totally clear.
HEART: Regular rate and rhythm without murmurs, gallops, or rubs.
ABDOMAN: Soft and obese. no palpable mass. No hepatosplenomegaly. Normal bowel sounds.
EXTREMITIES: Revealed no edema. Good pulses.
IMPRESSION: 1.A past hx of benign polyps, repeat colonoscopy
2. Stable coronary artery disease, status post two stent placements, on Plavix and aspirin, w/o hx of myocardial infarction.
3. High blood pressure
4. Non-insulin-dependent DM
5. Obesity, status post Lap band procedure.
PLAN: Schedule colonoscopy. The complications including bleeding, perforation and emergency surgery were explained to the patient in detail. He will check with his cardiologist regarding cessation of Plavix. he will stop aspirin one week prior to the procedure.
We billed the E/M 99204 with dx V12.72. Insurance denied because they only except Preventive codes with V codes.Can we change the E/M to Preventive(99386) just to satisfy their requirements?Thanks as always for your help.

 

[hewitt]

What was the intention of the visit? It does not sound to me that the patient came in because of problem they were having.... It sounds like an annual (check up) visit? The preventive E&Ms seem to fit better, from what I see here.... If you change to a preventive CPT, I think V12.72 should be the secondary diagnosis.

 

[ajs]

Ok, Ii am not sure what to do. i have a patient who was seen by one of our GI providers due to Hx of Colon Polyps((V12.72) The documenation reads:
CC: Previous surgery of colon polyps
HPI:A 64 year old referred by PCP for screening colonoscopy. He had previous polpys removed in the past. his last colonoscopy was seven years agao and was normal. he previously had no lower GI complaints and denies a Family hixtory of colon cancer. He has had stents placed and is on plavix . He will chcek with his cariologist for clearance before stopping Plavix.
PSFH done
Updated Medication was done.
ROS Done
PE; Gen: A pleasant white male who is overweight. No acute distress.
Vitals done
EYE: There are no jaundice or arcus senilis. My examination revealed good hygiene on teeth. No infiltrates.
NECK: Supple. Thyroid gland is not enlarged. There are no bruits.
Chest: totally clear.
HEART: Regular rate and rhythm without murmurs, gallops, or rubs.
ABDOMAN: Soft and obese. no palpable mass. No hepatosplenomegaly. Normal bowel sounds.
EXTREMITIES: Revealed no edema. Good pulses.
IMPRESSION: 1.A past hx of benign polyps, repeat colonoscopy
2. Stable coronary artery disease, status post two stent placements, on Plavix and aspirin, w/o hx of myocardial infarction.
3. High blood pressure
4. Non-insulin-dependent DM
5. Obesity, status post Lap band procedure.
PLAN: Schedule colonoscopy. The complications including bleeding, perforation and emergency surgery were explained to the patient in detail. He will check with his cardiologist regarding cessation of Plavix. he will stop aspirin one week prior to the procedure.
We billed the E/M 99204 with dx V12.72. Insurance denied because they only except Preventive codes with V codes.Can we change the E/M to Preventive(99386) just to satisfy their requirements?Thanks as always for your help.

You coded correctly for the services provided. You did not do a preventive exam so I would not change the CPT code. What I would do is appeal the denial and send the patient's chart note. This will probably be allowed in a claim review. It just needs to get past the initial denial edits some payers have built into their systems.

The patient was referred by the PCP for the history of colon polyps, I would include that information in the appeal.

 

[ajs]

What was the intention of the visit? It does not sound to me that the patient came in because of problem they were having.... It sounds like an annual (check up) visit? The preventive E&Ms seem to fit better, from what I see here.... If you change to a preventive CPT, I think V12.72 should be the secondary diagnosis.

The intention of the visit was to consult for a screening colonoscopy due to a history of colon polyps. This patient was referred by the PCP who very likely already did a routine annual physicial, hence the referral for the screening colonoscopy. I would make a case for appeal to the insurance carrier to review, sometimes their edits get in the way of correct coding.