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denied medicare colonoscopy

Karen Posted Wed 18th of July, 2012 15:54:41 PM

Billed medicare for a screening colonoscopy. CPT G0105 DX V76.51. Medicare denied "PR-150" Patient responsibility/Payment adjusted because payer deems the info submitted does not support this level of service. Per our records her last colonoscopy was 10 years/4 months ago. Please help.

SuperCoder Answered Wed 18th of July, 2012 16:21:57 PM

Please see these guidelines and note if you are following the proper way.

Screening colonoscopies will be performed on asymptomatic patients when they have attained the age for screening as a routine purpose. So you are right with using V76.51 (Special screening for malignant neoplasm, colon) as the primary diagnosis code when the first time the patient presents to your gastroenterologist and he decides to do a screening.

When your gastroenterologist records the patient's history and finds a family history of malignant neoplasm of the gastrointestinal tract or a personal history of malignant neoplasm of the large intestine, these findings should be recorded as secondary codes. So you will use V10.05 (Personal history of malignant neoplasm, large intestine), V12.72 (Personal history of colonic polyps) or V16.0 (Family history of malignant neoplasm, gastrointestinal tract) if your gastroenterologist records pertinent history in the documentation.

During routine screening, if your gastroenterologist finds nothing significant, then the procedure should be reported using diagnostic procedure codes such as 45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) for non-Medicare patients and G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for Medicare patients should be reported.

However, if your gastroenterologist finds a polyp or any other lesion, the colonoscopy is no longer screening and appropriate codes for removal should be reported.

Once the patient has had the polyp removed, the personal history of the polyp puts him in the high risk category for recurrence of the polyp.

In such a case scenario, the patient will need to be screened for neoplasms at a much earlier interval than a routine screening of ten years. You should use V12.72 as the primary diagnosis when the patient returns for a follow-up procedure in 3-5 years.

Some carriers may have their own policy about how these procedures should be coded but in general you should only use V76.51 for the initial average risk colonoscopy screening procedure and subsequent routine screening examinations performed at ten year intervals. Because routine screening is covered at 100 percent with no deductible or co-payment there are patients who will ask you to use V76.51instead of a high risk diagnosis code like V12.72. You should resist the temptation to incorrectly code a procedure to get an insurance company to cover the procedure

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