Wiki V67.09 help

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Please help. I have a facility that is using v67.09 (follow-up examination, following other surgery) as the primary diagnosis codes on colonscopies that are being ordered and scheduled for high risk screening patients (patients on a 5 year recall with a history of polyps etc). Since I code for the physician side of these, I never use that code and I am not sure that it is needed. The facility is having a difficult time with this code for the Medicare Part C plans. I have patients calling daily with Medicare part C plans regarding these copays. This diagnosis seems to be causing the procedure to pull the patient outpatient copays. I am wondering if there is any supporting information that I can see and show to the facility to help with this. I have contacted the Medicare Part C plan and they are not able to help with my question of whether this code is needed or not on these claims.
 
I am having the exact same issue (except not necessarily for Medicare C, but just in general). I have yet to find a concrete answer to this problem, I don't feel V67.09 is an appropriate code in these circumstances; however, the Medciare LCD for colonoscopies does show this is a medically necessary dx. If you find any information on this code please let me know. I've been doing a lot of research and have come up with nothing to support this code as a primary dx. The only thing I have heard, it's been explained to me that this is to let payers know this procedure is within the 10 year window from the initial dx of polyps so that they don't have to pay 100% for a second "screening" in less than 10 years. I've been advised to think of V67.09 as more of a modifier letting payers know the patient is under 10 years (this is all under the Affordable Care Act supposedly). I do not agree with this rationale until I have proof. Again, let me know if you do come across any helpful resources. Good luck to you!
 
Check with your MAC to see if they have specific coding guidelines to follow for facility coding.
Although I don't do outpatient facility coding (we have our own ASC), I don't feel V67.09 is appropriate for a primary dx for a 5 year recall, and I can't imagine why they would need that on their claim. A high risk surveillance colonoscopy should be submitted as G0105 (in the absence of any therapies), with the appropriate code that describes their high risk status. So, in this case, G0105/V12.72.
I would, however, use the v67.09 in cases such as a colonoscopy done 6 months after a polyp removal, to verify the polyp is completely gone.
Another thought...are they using the PT modifier?
 
v67.09

you will find the answer you need in the Medicare LCD for Colonoscopy's dated 1/22/2013. It is on page 3 item #4.
"Surveillance of a colonic neoplasia: When the pt has a history of colorectal cancer or polyps and is being followed for this indication, use the appropriate diagnostic CPT and code with ICD-9 CM code v67.09 as the primary dx and one of the following as secondary dx: V10.05,V10.06 or V12.72" it then goes on to give you senario's.
 
New FI Carrier NGS LCD's wanting -67.09 Prime Info

Help! We are a GI Specialty group New to NGS as of 9/6/13. The LCD's clearly state the need for use of -V67.09 on Surveillance colons following the surgical removal of polyps or cancers.
I've contacted specialists with NGS and they only tell me only to follow LCD Policy. It does not give specific info on the use following a personal hx of polyps and cancer. Nothing published on examples and the providers I've contacted in NY and Connecticut seem to be unaware of this policy since the claims clear MCR's NCD's. We need these procedures to go clean the first time, but have no resources to ask.
Is anyone in J6 in the same situation???
 
cms guidelines?

chewri said:
you will find the answer you need in the Medicare LCD for Colonoscopy's dated 1/22/2013. It is on page 3 item #4.
"Surveillance of a colonic neoplasia: When the pt has a history of colorectal cancer or polyps and is being followed for this indication, use the appropriate diagnostic CPT and code with ICD-9 CM code v67.09 as the primary dx and one of the following as secondary dx: V10.05,V10.06 or V12.72" it then goes on to give you senario's.
Click to expand...

I am searching to find this above referenced LCD update and am not locating it. Do you have a link for the above information? Below is the LCD on the CMS Website today regarding screening colonoscopies which reflects personal history under the high risk screening criteria.

Revision Effective Date

01/01/2011

Revision Ending Date


Indications and Limitations of Coverage and/or Medical Necessity

Cancer screening is a means of detecting disease early, in asymtomatic individuals, with the goal of decreasing morbidity and mortality. Generally, screening examinations, tests, or procedures are not diagnostic of cancer but instead indicate that a cancer may be present. The diagnosis is then made following a workup that generally includes a biopsy and pathologic confirmation. Colorectal cancer screening involves the use of fecal occult blood testing, rigid and flexible sigmoidoscopy, radiographic barium contrast studies, and colonoscopy.

Effective for services furnished on or after January 1, 1998, Medicare will cover colorectal cancer screening test/procedures for the early detection of colorectal cancer. The following are the coverage criteria for these screening services:


· Screening colonoscopies (code G0105) are covered at a frequency of once every 24 months for beneficiaries at high risk for colorectal cancer. High risk for colorectal cancer means an individual with one or more of the following:[/COLOR]
· A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;

· A family history of familial adenomatous polyposis;

· A family history of hereditary nonpolyposis colorectal cancer;

· A personal history of adenomatous polyps;

· A personal history of colorectal cancer; or

· A personal history of inflammatory bowel disease, including Crohn's Disease, and ulcerative colitis.
 
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