Monday, July 12, 2010

How to Adjust Procedure Coding to Abnormal Findings

Adjust Your Procedure Coding to Abnormal Findings

If the physician finds a lesion during a screening exam, you should no longer rely either G0105 or G0121 to describe the procedure. Instead, you would select the diagnostic colonoscopy (CPT Category I) code that properly identifies the resulting biopsy or removal.

For instance, if the physician discovers and biopsies a polyp during the exam for our 62-year-old, high risk patient described above, you would turn away from G0105 and instead report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).

Likewise, if the physician finds and removes by snare technique two colonic tumors during the exam of our 50-year-old patient, you would select 45383 (…with ablation of tumor[s], polyp[s] or other lesion[s] not amendable to removal by hot biopsy forceps, bipolar cautery or snare technique) over G0121.


Screening-Turned-Diagnostic Requires Second Diagnosis

Although your CPT coding will change entirely if the physician biopsies or removes a lesion during what began as a screening colonoscopy, you will not alter your primary diagnosis code. Instead, you should retain the appropriate V code as your first-listed diagnosis.

CMS instructions specify, “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” (Medicare Learning Network Matters article SE0746, “Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscopy”).

The official ICD-9 coding guidelines likewise state, “A screening code may be a first-listed code if the reason for the visit is specifically the screening exam.”

But, there’s a catch: Your diagnosis pointer should link an appropriate polyp diagnosis (not V code) to the diagnostic colonoscopy CPT code.

CMS explicitly requires this coding. In an example of a screening-turned-diagnostic colonoscopy, MLN Matters SE0746 instructs coders to enter a “2” in the diagnosis pointer (Item 24E on the CMS-1500 claim form), thus linking the CPT procedure code to the “line 2” diagnosis (that is, the polyp). Further language in the article makes clear that the “2” in Item 24E is “to link the procedure (polypectomy or biopsy) with the abnormal findings (polyp, etc.).”

Therefore, for the 62-year-old patient with a screening-turned-diagnostic colonoscopy with biopsy, you would enter procedure code 45380 in item 24.1.D of the CMS-1500 claim form. You would list a primary diagnosis of V10.05 (item 21.1) with a secondary diagnosis (item 21.2) that describes the polyp (for example, 211.3, Benign neoplasm of other parts of digestive system; colon). You would then place a “2” in item 24.1.E to “point” the diagnosis of 211.3 to the diagnostic colonoscopy procedure code.

In the case of the 50-year-old patient with a screening that evolved into diagnostic colonoscopy with polyp removal by snare technique, you would claim 45383 in item 24.1.D. The first-listed diagnosis (item 21.1) remains V76.51. For the secondary diagnosis (item 21.2), list the appropriate neoplasm diagnosis (such as 153.1, Malignant neoplasm of colon: transverse colon). Once again, you would list a diagnosis pointer of “2” in item 24.1.E.

Note: Medicare requires hospital outpatient departments to bill using form UB-04 (CMS-1450). On this form, you would enter the procedure code on line 44, listing the principal diagnosis on line 67, with secondary diagnoses in the additional boxes 67a-q. CMS provides no special instructions for filing this form with a screening-turned-diagnostic colonoscopy.

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