Colonoscopy Screening — Medical Coding Tips

Colonoscopy screening. The question is, “Doctor sees the patient in the office for screening colonoscopy.” So they’re like, “Is it V76.51 or V76.59?” “The doctor spends about 15 minutes with the patient and then we go in and spend another 10 minutes explaining prep to them and signing consent. So they’re upset. Now Medicare wants you not to be paid for the office visit? Is there a special code to use? Give the secret. How do I get that office visit paid?”

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So, you may not like my answer, but this is what our research showed. And you know, basically, we do these answer sheets. They’re like a scratch pad. It’s you know, what we encourage you to do to be your own you know, researcher. And I used to do a session on that local AAPC chapters on how to be your own consultant. Maybe I should bring that back and show people how to look up things like this.

So at any rate, colonoscopy screening. We need to look up these 2 codes that she referenced. V76.51 says screening for malignant neoplasm of the colon or it could be screening colonoscopy not otherwise specified. V76.49 is screening for malignant neoplasms other sites. So the answer, because she said it was a colonoscopy, is going to be V76.51. And if it’s high risk then it’s going to be V16.0 and that needs to be your lead code because that tells Medicare, right off the bat, that it’s a screening. And I know some of you are probably saying, “Well, doesn’t the procedure tell them that it’s a screening?” Yes but they use different fields to do particular edits. So in this case, they’re using the diagnostic field to do that. So when you do these screening colonoscopies, always lead with the V code.

Now I found some resources for you. MLN – Medicare Learning Network has great articles on things like this when you get stuck. So I recommend you go check this out. I can show you real quick. It looks like this. It’s a little more casual compared to some of their other types of documents but colorectal cancer, preventable, treatable and beatable, medicare-covered and billing for colorectal cancer screening. So if you are getting denied for something that you feel you should get paid for, these are great to reference in an appeal letter.

So you know, just kind of read through this and I did grab a piece of this. Where is it? Down here, this chart here: How To Bill Medicare and these are the codes that they want us to use when you’re billing Medicare for cancer screening. So G0104 is for when you do a to check that. 105 – colonoscopy on an individual at high risk so that should match up with that high risk V code. 106 is colon cancer screening when they use barium enema as an alternative to doing the flex sig. G0107* is FOBT 1-3 simultaneous determinations. That’s Fecal Occult Blood Test and the 1-3 simultaneous determinations are the little cards where they do the smear. So they do that 3 times. 120 – barium enema as an alternative to 105. So instead of the high risk one, they’re doing the barium enema one. 121 – colonoscopy for individuals not needing criteria for high risk. 122 – colon cancer screening barium enema, non-covered. So this is where you’re doing the colonoscopy. You know the patient doesn’t have any diagnoses or maybe it’s too frequent since the last time they had one, it’s not going to be covered. You have the patient sign the waiver but you still need to report to Medicare that it was done. The G0328, this is as an alternative to 107 using the Fecal Occult Blood Test. So a lot of choices for this particular procedure. So keep that in mind, those are all the different G codes for Medicare and I have this in the handouts.

*[Ed. note: G0107 is no longer in use.]

Colonoscopy Screening — Medical Coding Tips

Then there’s this other chart which is really excellent. I remember this when I was very first learning coding and billing. This is your Preventative Services chart. If you just go to and you type in “preventative services”, you’ll probably come across this PDF link. But notice on the left, it’s talking about the preventative services. We’ve got your initial preventative physical exam. We’ve got the annual wellness, the ultrasound screening for the triple A, the Abdominal Aortic Aneurysm. Cardiovascular screening, diabetes, medical nutrition, screening of pap, pelvic exam, screening mammos, bone mass…there’s the colon. Okay so colorectal cancer screening. Here’s all the G codes we just reviewed and then they also have this lab code, 82270 for the FOBT. They’re not specifying that you have to use particular diagnoses codes but we do know you need to lead with the V code. Who’s covered? And this is what becomes important with preventative medicine. They will pay for some preventative things but only so often and under certain criteria like patient age and things like that. So Medicare beneficiary has to be 50 or older, at normal risk of developing colorectal cancer or at high risk of developing colorectal cancer. And then high risk is defined in this particular CMS manual and they actually give you a nice little hyperlink if you want to go check that out.

The frequency, so we have age, now we talk about frequency. You can do the FOBT every year because that’s a fairly cheap, inexpensive test. The flex sig is once every 4 years, then a screening colonoscopy every 10 years or every 20 months if you’re at high risk. So the colonoscopy, by the way, is the one that’s all the way up, over, and down. So it’s the whole upside down view of the colon whereas the flex sig is just going to a portion of the descending colon. So if you had to divide it, you know, it’s about 1/3 of the way, if you will. And then barium enema is covered as an alternative every 2 years, okay? So that gives you an idea of the, you know, the frequency and other issues surrounding this.

I found this in my research on the AAPC discussion forum and I thought the person’s answer, I couldn’t do it better so I just copied it. So the questioner was saying if the patient comes in for screening only, V76.51 and also has a history of polyps, V12.72 or V16.0 of it was high risk… but the doctor finds polyps in the rectum and removes them by snare and a polyp in the cecum and removed by cold forceps, what is the correct billing? So she gives the 2 CPT codes. She gives the diagnosis and notice how leading with that V code? And then she says, “Make sure when you actually bill a claim that you do not designate a diagnosis pointer”, meaning a non-V code, “with your screening diagnosis code.” Okay so and her example here, 45385, the point was going to be 569.0 only. And then for the 45380.59 is going to be 211.3. In other words, you do not see the V codes listed on the claim form but it’s not linked to any of the procedures. The V code is to let Medicare know that the intent of the procedure was for screening. So they went in for screening, they found a polyp, they took care of the polyp. So it turned into a treatment but that wasn’t the intent.

Okay so now if nothing is found like there was no polyps then it would have been the G0105 or the 121, depending on whether they’re regular risk or high risk. And then the diagnosis would be the V76.51 to go with the G0121 or the V16 high risk one to go with the G0105 high risk screening.

Okay now going to the question about that E&M visit where they kind of prepping the patient for all this and feeling like, “Gee, that’s a lot of work. We should get paid for it.” Here is an article that I found in Find a Code which I use all the time to look up my codes online and it says, “While separate payment is not currently made for these visits, please schedule payment amounts for all procedures including colonoscopy-contained payment for the usual pre-procedure work associated with the procedure.” So I’ll just show you what that looks like.

So if you are a member of Find a Code, you have to sign in here. You can find articles like this and then you know, go ahead and you know, read it and that’s where I found that information. So I’m going to do that, I think, a session on how to be your own researcher, your own consultant. There you go.

So the bottom line… no pun intended… is that there is no office visit code to be billed. It’s just the colonoscopy. The discussion and prep is bundled into the procedure. So a long way to get you to know. Sorry, there was no magic pill for that one.

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