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Welcome - Read for Site Information!
Edited 10/12/2010
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Your coder is misinformed.
When there is a screening colonocopy, it is always coded with V76.51. The surgeon does not know/expect anything, since the patient is without sign/symptom.
Any findings and/or histories are coded as secondary - regardless of whether or not a biopsy or polypectomy is done.
If it's a diagnostic procedure - say, to do a re-check on a past problem (history of colon polyp) or to treat a current problem (polyp/tumor, bleeding), then there is no screening code at all; you would code for the actual condition, either a history of past condition or polyp, etc.
See below and note the last paragraph I cut & pasted from MLM article found here: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0746.pdf
"The relevant section of the 2007 MPFS states, regarding screening colonoscopies, that:
``if during the course of such screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening colonoscopy but shall be made for the procedure classified as a colonoscopy with such biopsy or removal.'' Based on this statutory language, in such instances the test or procedure is no longer classified as a ``screening test.'' Thus, the deductible would not be waived in such situations.
The above scenario can be restated as follows:
• A patient presents for a screening colonoscopy (or flexible sigmoidoscopy), and the patient has no gastrointestinal symptoms.
• During the subsequent screening colonoscopy (or flexible sigmoidoscopy), an abnormality is identified (such as a polyp, etc.), and it is biopsied or removed.
CMS advises that, whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination."
Short Soapbox "rant":
Your coder is to be commended for stepping up to give feedback and initiate change, but your coder needs to be cautioned to produce written backup for why coding should be done a certain way if it's different than what is currently being done.
When it comes to coding/billing rules/regs, never take anyone's word for it unless something can produce something in writing. Sadly, there are still a lot of myths & misinformation floating around that get passed down "because I told you so" and "we've always done it that way" and "we get paid when we do it like this.".
When you have the backup in writing from an authoritative source, such as a CMS or payer policy, you can reasonably presume that is the safe course to follow. Also remember that commercial payers don't always follow CMS rules, so it's equally important to look at those policies as well.
OK, off my soapbox.
Kudos to both of you for looking beyond. L J