Joseph Posted Wed 11th of July, 2012 14:56:51 PM
Can a claim be refiled as a corrected claim showing a screening colonoscopy for a patient at high risk due to family hx after it has been paid as a diagnostic claim showing patient had diarrhea and abnormal stool content? The insurance is BCBS and has paid on the diagnostic claim. I feel I know the answer to this question, as I know the guidelines for screenings, however, I need your opinion on this per request from our physcian.
SuperCoder Answered Wed 11th of July, 2012 21:06:20 PM
Code G0105 is used for reporting a screening colonoscopy for patients who are at high risk for colorectal cancer. High risk for colorectal cancer means an individual with one or more of the following:
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.
inflammatory bowel disease, including Crohn's Disease and ulcerative colitis.
If this is the case, definately you can refile the corrected claim, as per the guidelines above used.
Joseph Posted Thu 12th of July, 2012 12:40:58 PM
Thank you for your answer but I need to know the following. Although the patient has a family hx she had diarrhea and adomimnal distension among other symptoms. Although she has a family hx. the procedure was originally done based on CHRONIC DIARRHEA. Since this procedure was done and paid by BCBS based on an indication of CHRONIC DIARRHEA can we now bill for a screening because the patient is considered high risk? Thank you for any assitance you can give on this issue.
SuperCoder Answered Thu 12th of July, 2012 15:37:16 PM
One of the most common questions in many billing departments from patients is, "Why did you code my procedure as diagnostic? I have screening benefits and my colonoscopy was applied to my deductible. Can you re-file my claim as screening, so it gets paid?"
•First, you need to assess the patient's level of risk. Was the patient average risk and the coder simply put the common finding of CHRONIC DIARRHEA as the primary diagnosis? If so, simply correct the claim to show V76.51 as the primary diagnosis and CHRONIC DIARRHEA as the secondary diagnosis, and re-file to the insurance company as a corrected claim along with a copy of the colonoscopy report to show the patient was in fact here for colorectal cancer screening, and CHRONIC DIARRHEA was an incidental finding. The same process can be followed if a colon polyp is removed. Simply use V76.51 as the primary diagnosis and the colon polyp as the incidental finding, secondary diagnosis.
•Second, you need to assess the tools used and if there are polyps or other abnormalities found during screening colonoscopy. The type of intervention performed during the examination determines the procedure code. If a colon polyp or abnormality is encountered, there are many different removal techniques that can take place. For example, snare polypectomy (45385), hot biopsy forceps polypectomy (45384), or argon beam plasma coagulation fulguration (45383) or cold biopsy forceps (45380) can all be performed for colon or rectal polyp removal. Also, each of these procedure codes is reported only once regardless of the number of polyps removed.
•Third, 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.