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diagnostic colonoscopy vs screening

Kristine Posted Tue 19th of July, 2011 18:16:21 PM

If we have a pt that has had a screening colonoscopy 2 years ago with a polypectomy and we have the pt have a repeat colon, should this be billed as diagnostic or screening? Pt has commercial insurance that doesn't follow Medicare guidelines. We precert these as diagnostic due to the history of polyps. We bill as 45378 with a dx of V12.72. Our hospital states that these should be billed as screening with the dx of V76.51 as primary and V12.72 as secondary. Our claim is being paid but the hospital claim is not due to the fact that there hasn't been 10 years since the last screening. Any insight to the correct way to bill these would be much appreciated.

SuperCoder Answered Tue 19th of July, 2011 20:00:15 PM

V12.72 as primary is correct. Refer to the link below:
http://www.supercoder.com/articles/articles-alerts/gac/reader-questions-watch-out-for-screening-versus-surveillance/?zoom_highlight=v12%2E72
...
Even though, I understand that V12.72 should help reimbursement in these cases, but practically I have seen the denials with V12.72 as Primary Dx. In such events,I have seen many coders for the sake of reimbursement,use to check if they can code anything other than V codes, pertaining to GI problems/signs/symptoms, if not then 793.4 just because the reason that Medicare has a general tendency to deny V codes in most cases. Even though using 793.4 without any finding or symptoms etc sounds unethical for me, I would like to suggest you to check your carrier preference.

Kristine Posted Tue 19th of July, 2011 20:22:26 PM

That helps with the dx but what about the procedure code? We use 45378 but the hospital is billing with a screening procedure code. They claim that they have guidelines to go by and in April they received new guidelines telling them that these colonoscopies should be billed as screenings even though the patient had a screening within the last 5 years. We feel these are surveillance colonoscopies not screening colonoscopies.

SuperCoder Answered Tue 19th of July, 2011 22:14:26 PM

By the time I will find time to come up with an answer specific to your question, I suggest you to go through another info for new colonoscopy coverage guidelines:
http://www.healthcare.gov/law/provisions/preventive/index.html

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