Susan Posted Fri 25th of May, 2012 15:10:38 PM
Insurance companies telling patients their claim was coded incorrectly, it sould have been a prevenative when claim was billed as a prevenative.
If a patient has an initial screening V76.51 and polyps are biopsied or
removed the procedure becomes diagnostic but the V76.51 stays as the primary dx code, then the findings secondary. Now patient returns due to
hx of polyps, I use V12.72 as primary then any findings as secondary. However, insurance is still telling the pt claim should have been billed as screening V76.51. But if I used the V76.51 isn't that incorrect because patient has already had their initial screening? Please help already
SuperCoder Answered Fri 25th of May, 2012 17:16:43 PM
There are two types of colonoscopy services: diagnostic or therapeutic. In some cases a diagnostic colonoscopy may be converted from diagnostic to therapeutic based on the patient's clinical findings and the procedure performed.
Screening Colonoscopies are performed on patients that have no presenting signs or symptoms related to the digestive system, but have reached the age for routine screenings.
ICD-9- CM diagnosis code V76.51 (Special screening for malignant neoplasm, colon) is always the first listed diagnosis code regardless of the findings. All additional findings are reported as secondary codes.
The following ICD-9-CM diagnostic V-codes should be listed as secondary codes when the information is listed in the patient's record (usually in the history and physical). The following codes also note that the patient is considered high risk (See high risk circumstances below.)
Personal history of malignant neoplasm, large intestine
Personal history of colonic polyps
Family history of malignant neoplasm, gastrointestinal tract
When signs and symptoms are related to the GI tract (i.e., abdominal pain, blood in stool, chronic diarrhea, change in bowel habits, weight loss or blood loss anemia), the above mentioned V-code (V76.51) should never be assigned. A symptom code should be assigned when there is no definitive diagnosis. If the patient's history notes a family history or personal history of colonic malignancy or polyps, the appropriate V-code from the box above should be assigned as a secondary code.
You need to assess the actual medical necessity behind performing the colonoscopy in the first place. It would not be medically necessary for an asymptomatic average risk patient (V76.51) to be screened at a two, three or five-year interval. However, it might be medically necessary for an asymptomatic high-risk patient (V12.72, V16.0, etc.) to be screened every two, three or five years, therefore the diagnosis code used should reflect that.