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ins carrier that doesn't recognize V10.05 as screening

Sophie Posted Thu 25th of April, 2013 20:42:15 PM

We have patients from time to time who's benefit plan doesn't recognize high risk screening codes, ie: V10.05,V12.72 and will apply their diagnostic beneftis instead of screening/preventative benefits. I've been tought that you can't bill V76.51 (low risk screening) as primary dx on a high risk pt. You have to list the high risk code as primary. Just wondering how to handle these cases. I can't really find any set in stone guidelines. Any EVERYONE has different opinions.

pt is having colonoscopy for personal hx colon ca, V10.05. Nothing was found during procedure and we billed 45378 w/ V10.05 but the patients plan doesn't recognize V10.05 under screening benefits. They only recognize V76.51 so the patients diagnostic benefits were applied. (**also this carrier doesn't accept Mecidare code G0105)

SuperCoder Answered Wed 01st of May, 2013 15:49:04 PM

Regardless of findings, stick to V10.05 to describe condition.

Accurately reporting colorectal cancer screenings on patients at high risk for the disease can hinge on fine points like assigning the right V code.

Examine the following scenario sent in by Dawn Duchesney of DeMasi Digestive Health, Venice, FL and the coding advice that follows to finesse these claims -- and recoup your deserved reimbursement for these services:

Scenario: Our patient has a personal history of colon cancer, having undergone treatment for colon cancer six years ago, but she is currently experiencing no symptoms. Her 2006 colonoscopy came out clear, and so did her recent one performed about a month ago. We billed 45378 for the procedure, and V10.05 for the diagnosis. However, the patient called complaining we should've billed the procedure as routine since her last two colonoscopies were clean. How should we resolve this?

Select G0105 Or 45378, But Get The History Diagnosis Right

If you're billing Medicare, you should report the procedure as a high risk screening with code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). Then, report V code V10.05 (Personal history of malignant neoplasm of large intestine) as the primary diagnosis.

Code V10.05 fits the bill for primary diagnosis because the patient presents to the office for a screening exam and not specifically for follow-up evaluation of the cancer. If the encounter's purpose is for cancer surveillance and follow-up at an interval close to the surgical treatment, you could instead code V67.09 (Follow-up examination following other surgery) as your primary diagnosis. However, keep in mind that this ICD-9 code is rarely used, warns Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT® Advisory Panel.

On the other hand, some commercial carriers would require the code 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]) with modifier 33 (Preventive services) appended to denote that the service was preventive, and the V code V10.05 as diagnosis, advises Christine M. Greene, Southwestern Vermont Health Care, Bennington, VT.

The use of modifier 33 relates to mandated preventive services performed in order to comply with the Patient Protection and Affordable Care Act (PPACA), which requires all health care insurance plans to begin covering preventive services and immunizations without any cost-sharing. The American Medical Association (AMA) defines this modifier as:

Modifier 33, Preventive service: When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.

(Check out for more details.)

"CPT® modifier 33 has been created to allow providers to identify to insurance payers and providers that the service was preventive under the applicable laws, and that patient cost-sharing does not apply," according to AMA. This means that a patient's co-insurance, co-payment, and deductible are waived for the applicable services (in this case, 45378).

Note: The list of specific preventive services for which cost-sharing does not apply for patients includes colorectal cancer screening tests.

Don't forget: List V10.05 as your primary diagnosis for both circumstances (Medicare and commercial payers), whether the results were clear or not. Use this code if all treatment directed toward the cancer is complete and there are no indications of current disease. Don't make the mistake of reporting a cancer code (153.3, Malignant neoplasm of sigmoid colon) or the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract).

Draw On Diplomacy To Confer With Patients

Such complaints from patients on a screening colonoscopy are commonplace in the gastroenterology practice. The best advice is to talk it out with your patient, and clarify how their cancer history affects the coding. Explain that colonoscopies are not routine. A routine colorectal screening would take place every 10 years for a person with no risk or cancer history. On the other hand, a high-risk patient with history or polyps or cancer would usually present to the physician's office sooner than 10 years.

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