Billing Screening Colonoscopy , Flexible Sigmoidoscopy

Coding for Screening Colonoscopy & Flexible Sigmoidoscopy

When billing for colonoscopy or flexible sigmoidoscopy services, it is important that providers assign the correct ICD-9-CM diagnosis, as the diagnosis code is used to determine the applicable member benefit, which in turn determines member liability. While preventive benefits are applied to screening colonoscopies or flexible sigmoidoscopies (reported with a screening diagnosis V-code), non-preventive benefits are applied for colonoscopies or flexible sigmoidoscopies reported with diagnosis codes for specific illnesses, signs or symptoms.

National ICD-9-CM guidelines for coding and reporting
To ensure accurate assignment of diagnosis codes, providers should follow the ICD-9-CM Official Guidelines for Coding and Reporting, which have been jointly developed by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)---two agencies within the U.S. Department of Health and Human Services.

These guidelines provide specific directions for determining whether or not a service is being performed for screening or diagnostic purposes:
• "Screening" is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease.
• The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test. (Examples: rectal bleeding, unexplained iron deficiency anemia, unexplained weight loss)
• A screening code should be the first listed diagnosis code if the reason for the visit is specifically a screening exam.
• If a condition is discovered during the screening, then the code for the condition should be assigned as an additional diagnosis.
These guidelines also provide the following direction for those cases where the member has a personal and/or family history of malignant neoplasm:
• Personal history codes may be used in conjunction with the follow-up codes
• Family history codes may be used in conjunction with screening codes to explain the need for a test or procedure.
It should be noted that for both personal and family history codes, they are to be used in conjunction with follow-up and screening codes. To ensure that the correct member benefit is applied, it is important that the screening or follow-up code be the first listed code followed by the history code.