A Non-Medicare patient presents for a screening colonoscopy due to a polyp that was removed X years ago. The patient currently has no signs or symptoms. This patient has a high risk determination (history of colon polyps, denoted by HCPCS code V12.72) so the procedure would be scheduled as a screening colonoscopy on an individual at high risk (HCPCS G0105). During the screening exam, the physician discovers a polyp in the colon and removes it with a snare technique. Based on the definition of and requirements for modifier -33, the correct code assignment for this scenario is 45385-33. The claims processing system should read this as the initial procedure was expected to be a screening colonoscopy but a polyp was identified and removed in the same encounter.

What dx code would be the primary, the history of the polyp V12.72 or the polyp that was the finding 569.0?

The Primary Dx would be 211.3 for the polyp adenomatous.

Does anyone no of a code for GI Dysmotility

What if they don't initally do the procedure for Diarrhea it is done for a screening, then when he is doing the procedure he does a bx of the colon to r/o microscopic colitis due the chronic diarrhea? Would you still code as a screening turned diagnostic?

I would recommend using 536.9 for this

I have forwarded this query to my editor. We want to be sure you get the definitive answer.

Thanks.

EGD with balloon dialtion of cystgastrostomy, Pancreatic necrosectomy and nasogastric drainage placemnet

Indication: Pancreatic nectosis, abscess
The stomach was entered with ease. The stomach showed debris at the recently created fistula at the lesser curvature. A CRE balloon dilation of the opening was performed to 20mm. then the lesser sac was entered and debris was removed with a snare tripod, roth net and forceps. 3l of NS were used to flush the cavity. At the end of the debridment, viable, mildly oozing granulation tissue was seen. A pigtail nasocystic catheder was placed into th ecavity and clipped with two resolution clips. the Duodenum was normal.
Final Diagnosis: Pancreatic Necrosis

Any suggestions on the CPT coding of this procedure?

A screening colonoscopy is a procedure on a patient who has no symptoms. Commercial payors accept either of two coding possibilities for screening colonscopies. Some payors accept the HCPCS code G0121 (screening colonoscopy for average risk), initially only used by Medicare but now more widespread among commercial payors. Other payors, however, accept CPT 45378 (colonoscopy diagnostic) with a diagnosis code of V76.51 (colon screening for malignant neoplasm).

However, if a polyp or lesion is found and removed by snare during the screening colonoscopy, coding becomes more complicated. Now the procedure is billed as 45385 (colonoscopy with lesion removed by snare) and the selection of diagnosis code is a little more difficult. In your case, if biopsy is done, you bill 45380 and link with chronic diarrhea ICD code.

If a lesion is found during the colonoscopy, both the indication of screening and the finding should be billed.

If the procedure is a screening colonoscopy, the indication should not be a symptom. The gastroenterologist should be alerted and the note amended.

necrosectomy was done through the endoscopy. There was no surgical incision made. I understand 48105 to be an open procedure. Is this correct?

In that case there is no choice but to code it with an unlisted code 48999 and compare it with 48105.

We have patients from time to time who's benefit plan doesn't recognize high risk screening codes, ie: V10.05,V12.72 and will apply their diagnostic beneftis instead of screening/preventative benefits. I've been tought that you can't bill V76.51 (low risk screening) as primary dx on a high risk pt. You have to list the high risk code as primary. Just wondering how to handle these cases. I can't really find any set in stone guidelines. Any EVERYONE has different opinions.

example:
pt is having colonoscopy for personal hx colon ca, V10.05. Nothing was found during procedure and we billed 45378 w/ V10.05 but the patients plan doesn't recognize V10.05 under screening benefits. They only recognize V76.51 so the patients diagnostic benefits were applied. (**also this carrier doesn't accept Mecidare code G0105)

In the 03-21-13 issue, you mentioned that cholangiogram is an integral component of ERCP and cannot be billed separately. Were you only referring to the fluoro codes? We bill out '74328-26' for the gastroenterologist's interpretation of the cholangiogram.

I would like clarification on the Administration code that should be used for Humira and Cimzia. How would it be correct to say you use 96401 for the administration of Cimzia; however, you use 96372 for the administration of Humira. When I am reading the posts on Supercoder this is what is being said. If you read the information before the code 96401 it says this code can be used for treatment of noncancer diagnoses. Humira and Cimzia both are biological agents. So if it is correct to use 96401 for Cimzia, why would it not be correct to use 96401 for Humira?

Radiologists frequently perform RS&I when gastroenterologists perform ERCP surgeries (43260-43272). You should select the most appropriate of the following three codes to describe the radiologist's work depending on the radiologist's documentation:

74328 Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation

74329 Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation

74330 Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiologicalsupervision and interpretation.

Scenario:

If what your gastroenterologist does is scope the patient and collect samples, you'd only code 43260 (Endoscopic retrograde cholangiopancreatography [ERCP]; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). That code includes the collection of samples.
The second code, 74328 (Endoscopic catheterization of biliary ductal system, radiological supervision and interpretation), is a radiology code for directing a catheterization, not a diagnostic procedure.
If your physician did, in fact, have the patient catheterized, you would be able to report 74328 (Endoscopic catheterization of biliary ductal system, radiological supervision and interpretation), but only if you can check off three items:
• The gastroenterologist must indicate in his notes that he supervised the ERCP, and he must also include in the note his interpretation of the procedure.
• No other physician may claim the same service.
• You should append modifier 26 (Professional component) to 74328, as appropriate, if your gastroenterologist provides the service in a facility setting.

My editor is working on this. Please be patient.

Thanks.

The code 96401 says in the descriptor: "non-hormonal, anti-neoplastic". Also the sectional guideline above code 96401 says: "Chemotherapy administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (eg, cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal antibody agents, and other biologic response modifiers."

See the first portion of the guideline that says about "anti-neoplastic" drug. It also says that it applies to "anti-neoplastic agents provided for treatment of noncancer diagnoses". this section (96401-96549) is for highly complex drug/biologic agents.

As per CPT Assistant May 2007; Volume 17: Issue 5 ("Drug Administration Services—Part 1 of 3") -->

"We are frequently asked whether the chemotherapy codes apply to all monoclonal antibody agents and other biologic response modifiers even when used for noncancer diagnoses, or whether code usage is applicable only when used for cancer diagnoses. Codes 96401-96549 describe chemotherapy services that are typically highly complex, requiring direct physician supervision and advanced training and competency for the staff providing these services. CPT 2007 (page 411 of the professional edition) indicates that "Chemotherapy administration codes 96401-96549 apply to parenteral administration of non-radionuclide, anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (eg, cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers." The mentioned drugs are only examples and do not suggest or imply any payer coverage. The codebook does not designate whether a specific drug or agent is reportable using this series of codes. Coverage determinations for specific drugs and agents are made by each third-party payer......

The provider is cautioned not to assume that the 96000 series of CPT codes would be appropriately reported for every biologic response modifier, chemotherapeutic drug, or monoclonal antibody agent. For example, the CPT Editorial Panel Drug Infusion Workgroup addressed questions related to the infusion of Leucovorin and Mesna, drugs commonly utilized in addition to an antineoplastic agent infusion. The members indicated that although these drugs are included in the HCPCS Drug Category for Chemotherapy Drugs, their inclusion in the J9000 series was done as a matter of coding convenience as these drugs are not antineoplastic agents but either modulate the effect of the antineoplastic agent or protect normal tissues. The workgroup agreed that these drugs administered as modulating agents in addition to antineoplastic agent infusion should not be reported with codes in the 96000 series of codes but would be reported appropriately by a concurrent or sequential therapeutic infusion or injection code(s), depending upon the circumstances related to the hierarchy and method of administration."

So here lies the confusion of which code to bill for ADMINISTRATION of a drug since there is no clear instruction. Coders should check with payers before using 96401 to report a drug admin. CPT’s chemotherapy administration introductory notes allow the use of chemotherapy administration codes for other non-chemotherapy agents. The definition created in 2006 meant chemotherapy administration codes can apply to substances, such as monoclonal antibody agents.

Prior to 2006, CMS had created a partial list of drugs that qualified for chemotherapy administration codes. “The following drugs are commonly considered to fall under the category of monoclonal antibodies: infliximab, rituximab, alemtuzumab, gemtuzumab, and trastuzumab,” according to CMS Transmittal 129. The list, however, did not include Omalizumab (Xolair) or Certolizumab (CimZia), but both these drugs are considered "another drug in the same monoclonal antibody category".

CMS’ partial drug list left discretion to individual carriers. Coding specialists indicate that “certain insurance carriers will reimburse for the more complex code, 96401, generally paid at a higher level, but usually reserved for chemotherapy administration via the subcutaneous route.

Here is one more example in the same debate. Because omalizumab is not an anti-neoplastic monoclonal antibody, the American Thoracic Society (ATS) and the American College of Chest Physicians (ACCP) recommend the use of 96372.

Some payers have followed suit and frown on using chemotherapy administration code 96401 for omalizumab, which is a non-chemotherapy drug. For instance, Cigna Part B for Idaho, North Carolina and Tennessee requires the use of 96372 for Xolair administration. The Medicare carrier agrees that “Xolair (omalizumab) is a monoclonal antibody ... But because Xolair is not an anti-neoplastic as required by 96401, it would be incorrect to bill for administration of Xolair under CPT code 96401, Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.”

Instead, the Cigna Government Services July 5, 2006, article “Drug Administration Coding” instructs coders to bill the administration of the drug based on the route of administration using 96372, Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular.

CPT confirms that you should use 96372 for non-antineoplastic hormonal therapy injections. “Report 96401 for anti-neoplastic hormonal injection therapy.”

It's best, therefore to inquire with the payer to finalize which administration you could use for particular drug.

Please check the CIMZIA website's page on "Quick Reference coding guidance" -->

http://www.cimzia.com/cimplicity/pdf/Quick%20Reference%20Coding%20Guide%20DR.pdf

This page, developed by Cimzia itself, has 2 options as CPT code - 96372 and 96401 :-)

Regardless of findings, stick to V10.05 to describe condition.

Accurately reporting colorectal cancer screenings on patients at high risk for the disease can hinge on fine points like assigning the right V code.

Examine the following scenario sent in by Dawn Duchesney of DeMasi Digestive Health, Venice, FL and the coding advice that follows to finesse these claims -- and recoup your deserved reimbursement for these services:

Scenario: Our patient has a personal history of colon cancer, having undergone treatment for colon cancer six years ago, but she is currently experiencing no symptoms. Her 2006 colonoscopy came out clear, and so did her recent one performed about a month ago. We billed 45378 for the procedure, and V10.05 for the diagnosis. However, the patient called complaining we should've billed the procedure as routine since her last two colonoscopies were clean. How should we resolve this?

Select G0105 Or 45378, But Get The History Diagnosis Right

If you're billing Medicare, you should report the procedure as a high risk screening with code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). Then, report V code V10.05 (Personal history of malignant neoplasm of large intestine) as the primary diagnosis.

Code V10.05 fits the bill for primary diagnosis because the patient presents to the office for a screening exam and not specifically for follow-up evaluation of the cancer. If the encounter's purpose is for cancer surveillance and follow-up at an interval close to the surgical treatment, you could instead code V67.09 (Follow-up examination following other surgery) as your primary diagnosis. However, keep in mind that this ICD-9 code is rarely used, warns Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT® Advisory Panel.

On the other hand, some commercial carriers would require the code 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]) with modifier 33 (Preventive services) appended to denote that the service was preventive, and the V code V10.05 as diagnosis, advises Christine M. Greene, Southwestern Vermont Health Care, Bennington, VT.

The use of modifier 33 relates to mandated preventive services performed in order to comply with the Patient Protection and Affordable Care Act (PPACA), which requires all health care insurance plans to begin covering preventive services and immunizations without any cost-sharing. The American Medical Association (AMA) defines this modifier as:

Modifier 33, Preventive service: When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.

(Check out http://www.ama-assn.org/resources/doc/cpt/new-cpt-modifier-for-preventive-services.pdf for more details.)

"CPT® modifier 33 has been created to allow providers to identify to insurance payers and providers that the service was preventive under the applicable laws, and that patient cost-sharing does not apply," according to AMA. This means that a patient's co-insurance, co-payment, and deductible are waived for the applicable services (in this case, 45378).

Note: The list of specific preventive services for which cost-sharing does not apply for patients includes colorectal cancer screening tests.

Don't forget: List V10.05 as your primary diagnosis for both circumstances (Medicare and commercial payers), whether the results were clear or not. Use this code if all treatment directed toward the cancer is complete and there are no indications of current disease. Don't make the mistake of reporting a cancer code (153.3, Malignant neoplasm of sigmoid colon) or the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract).

Draw On Diplomacy To Confer With Patients

Such complaints from patients on a screening colonoscopy are commonplace in the gastroenterology practice. The best advice is to talk it out with your patient, and clarify how their cancer history affects the coding. Explain that colonoscopies are not routine. A routine colorectal screening would take place every 10 years for a person with no risk or cancer history. On the other hand, a high-risk patient with history or polyps or cancer would usually present to the physician's office sooner than 10 years.