Consider patient history and reason for the visit for accurate diagnosis coding.
The advent of the Affordable Care Act (ACA) has increased patient access to a greater number of preventative services. Physicians and patients have both benefited from this new law. Patient disease processes are being diagnosed at an earlier stage, ensuring less invasive treatments and better outcomes, while physicians are seeing an increase in revenue for preventative services.
Practices performing colonoscopies for colon and rectal cancer screenings have seen a corresponding rise in requests for “screening” colonoscopy. As a result, there is an increase in incorrectly coded colonoscopies. Practices may not understand that a majority of patients are actually not screening colonoscopies, but are following surveillance regimens. There are several steps you must take to determine the difference and correctly code colonoscopy.
Step 1: Define Screening vs. Surveillance Colonoscopy, Determine Patient Need
Physicians and coders must be able to distinguish between a screening and surveillance colonoscopy. As defined by The U.S. Preventive Services Task Force (USPSTF):
A screening colonoscopy is performed once every 10 years for asymptomatic patients aged 50-75 with no history of colon cancer, polyps, and/or gastrointestinal disease.
A surveillance colonoscopy can be performed at varying ages and intervals based on the patient’s personal history of colon cancer, polyps, and/or gastrointestinal disease. Patients with a history of colon polyp(s) are not recommended for a screening colonoscopy, but for a surveillance colonoscopy. Per the USPSTF, “When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.”
The USPSTF does not recommend a particular surveillance regime for patients who have a personal history of polyps and/or cancer; however, surveillance colonoscopies generally are performed in shortened intervals of two to five years. Medical societies, such as the American Society of Colon and Rectal Surgeons and the American Society of Gastrointestinal Endoscopy, regularly publish recommendations for colonoscopy surveillance.
The type of colonoscopy will fall into one of three categories, depending on why the patient is undergoing the procedure.
Diagnostic/Therapeutic colonoscopy (CPT® 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))
Patient has a gastrointestinal sign, symptom(s), and/or diagnosis.
Preventive colonoscopy screening (CPT® 45378, G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
Patient is 50 years of age or older
Patient does not have any gastrointestinal sign, symptom(s), and/or relevant diagnosis
Patient does not have any personal history of colon cancer, polyps, and/or gastrointestinal disease
Patient may have a family history of gastrointestinal sign, symptom(s), and/or relevant diagnosis
Exception: Medicare patients with a family history (first degree relative with colorectal and/or adenomatous cancer) may qualify as “high risk.” Colonoscopy for these patients would not be a “surveillance,” but a screening, reported with HCPCS Level II code G0105 Colorectal cancer screening; colonoscopy on individual at high risk.
Surveillance colonoscopy (CPT® 45378, G0105)
Patient does not have any gastrointestinal sign, symptom(s), and/or relevant diagnosis.
Patient has a personal history of colon cancer, polyps, and/or gastrointestinal disease.
Step 2: Properly Report Personal/Family History with Screening/Follow-up
According to ICD-9-CM Official Guidelines for Coding and Reporting, section 18.d.4:
There are two types of history V codes, personal and family. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure.
Common personal history codes used with colonoscopy are V12.72 and V10.0x Personal history of malignant neoplasm of the gastrointestinal tract. The family history codes include V16.0 Family history of malignant neoplasm of the gastrointestinal tract; V18.51 Family history of colonic polyps; and V18.59 Family history of other digestive disorders. Lastly, V76.51 describes screening of the colon.
Per the ICD-9-CM official guidelines, you would be able to report V76.51 (screening) primary to V16.0 (family history of colon polyps). In contrast, you would not use V76.51 (screening) with V12.72 (personal history of colon polyps) because family history codes, not personal history codes, should be paired with screening codes. Personal history would be paired with a follow-up code.
Just because you get paid doesn’t mean the coding is correct: Most carriers will pay V76.51 with V12.72 because their edits are flawed and allow it. The patient’s claim will process under a patient’s preventative benefits with no out-of-pocket; however, an audit of the record with the carrier guidance will reveal that the claim incorrectly paid under preventative services when, in fact, the procedure should have paid as surveillance. The best strategy is to contact your payer to be sure you are coding correctly based on that payer’s “screening vs. surveillance” guidelines.
Step 3: Understand Government and Carrier Screening Definitions
Following USPSTF recommendations, the ACA preventative guidelines state patients with a personal history of adenomatous polyps and/or colon cancer are not covered under a screening guidance, but rather under a surveillance regimen. Many third-party payers also have incorporated the personal history, shortened interval surveillance colonoscopy concept into their policies.
Surveillance colonoscopies are most often covered under diagnostic benefits, even if the patient is asymptomatic. Guidelines are inconsistent across payers; check with your individual payers for their guidelines.
Step 4: Educate the Patient
Under the ACA, payers must offer first-dollar coverage for screening colonoscopy but are not obliged to do so for a surveillance or diagnostic colonoscopy. The patient’s history and findings determine the reason for and type of colonoscopy, driving the benefit determination. This can be very frustrating for patients who may not understand why they are being charged for what they thought was a covered, physician-recommended “screening.” In fact, that screening might be a follow-up (surveillance) colonoscopy, or may become a diagnostic colonoscopy if there are findings.
To avoid angry, confused patients, educate them about the types of colonoscopy (preventative, surveillance, or diagnostic) and insurance benefits associated with each procedure. Accomplish this by providing the patient with the correct tools. Atlanta Colon and Rectal Surgery ask patients to review the “Colonoscopy: What You Need to Know” form (see Form A) prior to coming into the office to schedule their procedure. This form includes defining the patient procedure type, giving the patient the CPT® and ICD-9-CM codes to call insurance, and informing them of the practice policy of not illegally changing documentation to produce better benefit determination.
During the scheduling process, the scheduler will present the “Colonoscopy Notification Form” (see Form B), and discuss the patient’s responsibility for obtaining his or her insurance benefit.
Step 5: Correctly Apply the Principles
Scenario 1: An asymptomatic patient is scheduled for a colonoscopy. The patient had an adenomatous polyp removed from the descending colon two years ago. The patient has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
Rationale: The patient’s last colonoscopy was two years ago. He is being followed by a surveillance regime due to his history of polyps. ICD-9-CM guidelines do not allow the use of the V76.51 screening code with the V12.72 personal history code.
Scenario 2: An asymptomatic patient is scheduled for a colonoscopy. The patient is 50-years-old and has a mother who was diagnosed with colon cancer at age 55. The patient has never undergone a colonoscopy and has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
ICD-9-CM: V76.51, V16.0
Rationale: The patient is 50-years-old and never undergone a colonoscopy procedure. His only relevant history is a mother with colon cancer; family history. ICD-9-CM guidelines allow the use of the V76.51 screening code with the V16.0 family history code.
Scenario 3: An asymptomatic Medicare patient is scheduled for a colonoscopy. The patient had an adenomatous polyp removed from the transverse colon five years ago. The patient has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
HCPCS Level II: G0105
Rationale: This is a Medicare patient with a history of adenomatous polyps undergoing a colonoscopy only five years from the last one. The patient is considered high risk under Medicare guidelines. ICD-9-CM guidelines do not allow the use of the V76.51 screening code with the V12.72 personal history code.
Scenario 4: An asymptomatic Medicare patient is scheduled for a colonoscopy. The patient was recently diagnosed with breast cancer and has never undergone a colonoscopy. The patient has no other personal or family history. The patient is scheduled and undergoes a complete bowel preparation followed by a colonoscopy to the cecum. No abnormalities are found.
HCPCS Level II: G0121
ICD-9-CM: V76.51, 174.9 Malignant neoplasm of breast (female), unspecified
Rationale: This is a Medicare patient with no personal or family history of gastrointestinal disease; breast cancer is not considered an indication under Medicare guidelines. The patient is classified as an average risk screening.
Screening and surveillance colonoscopy coding is driven by the diagnosis and reason for the visit. Physicians and coders must take the time to educate themselves on the definition and guidelines, both coding and carrier, to correctly bill colonoscopies.