Posts Tagged ‘medical coding’

In this month’s Southern California Physician magazine AAPC member Hidy Borden LPN, CPC, CPC-I discusses how to overturn reimbursement denials or avoid them in the first place. This article is not available online, but can be found on page 10 of the February issue.

It is important to remember that the front office sets the impression for the entire practice. Freda Brinson, CPC, CPC-H, CEMC shares the value of patient interaction as well as the little things like appointment reminders. This article provides a good overview of improving office efficiency and the role that coders play.

 Full Article

Brad Ericson, MPC, CPC, COSC shared his perspective on the need for good medical coders to possess a basic understanding of medical terminology and human anatomy. This fundamental background is key to selecting the correct diagnostic and procedural codes based on a physician’s notes written in medical language.

Full Article

Coders and their providers can bone up on coding, regulation, compliance, and billing while earning continuing education units (CEUs) and continuing medical education (CMEs) at AAPC’s 2010 National Conference in Nashville, Tenn. on June 6–9.  This annual event draws thousands of attendees including doctors, medical coders, and office/practice managers to connect on the business side of health care.  This is the first conference to be approved for 15.75 CME (AMA PRA Category 1™) credits.

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Budget cuts in education and compliance programs may be penny wise but dollar foolish.

By Michael D. Miscoe, JD, CPC, CASCC, CUC, CHCC

Under the False Claims Act (FCA), a health care facility or entity may be held liable for the conduct of its individual employees, or even the conduct of other entities with which it contracts or associates. This holds true even where the health care facility or group practice entity has no knowledge that its employee or contracted entity engaged in the preparation or submission of false claims.

The FCA allows a private-party plaintiff (a qui tam relator or “whistleblower”) to bring suit on behalf of the United States to recover monies paid to persons or entities who submitted false claims to the government. Actions also may be brought by the government directly.

If found guilty, the offending party can be held liable for a civil penalty from $5,500 to $11,000 for each false claim submitted, as well as three times the amount of actual damage to the federal government. Where the action is initiated by a whistleblower/qui tam relator, the defendant also may be required to pay the relator’s costs and attorney’s fees. The two primary statutes relevant to these actions are 31 U.S.C. §3729, which provides the statutory basis for liability, as well as the penalties for violation; and 31 U.S.C. §3730, which provides the statutory requirements for filing of a private civil (qui tam) action, on behalf of the government, against a person or entity who is alleged to have violated 31 U.S.C. §3729.

Liability Doesn’t Require Intent

An action for making a false or fraudulent claim for Medicare or Medicaid reimbursement may be brought when: 1) a false claim (or statement in support of a claim), 2) was presented or caused to be presented to the United States, 3) with the knowledge that the claim or statement was false, and 4) the false claim caused damage to the government.

Although the FCA requires “knowing” presentment of a claim containing false material, the statute (31 U.S.C. §3729(b)) expressly states, “No proof of specific intent to defraud is required.” The statute broadly defines the terms “knowing” and “knowingly” as including “actual knowledge,” “acts in deliberate ignorance of the truth or falsity” of the information submitted on the claim, or “acts in reckless disregard of the truth or falsity of the information” submitted on the claim form. That is, knowledge is imputed (assumed) where it can be shown that the entity acted with reckless indifference or deliberate ignorance.

For example, a single physician in a multi-physician practice group routinely up-codes claims. If the practice fails to take steps to ensure the validity of the claim data, or assumes a “see no evil” approach to billing, the group could be liable under the FCA for recklessly allowing false claims submissions, or for deliberately ignoring evidence that false claims were submitted. Such allegations against the group are especially likely where the government or qui tam relator is confident that it has a better chance of obtaining payment of penalties and damages from the facility. Even in cases where the group practice is not found to have sufficient knowledge, it likely will incur legal expenses to defend itself or the targeted party.

An implied false certification claim under the FCA is based on the principle that the simple act of submitting a claim for reimbursement implies compliance with all governing rules that are a precondition of payment (Mikes v. Straus, 274 F.3d 687, 699 (2nd Cir. 2001)). Although courts have reiterated consistently that mistakes — and even negligence — are not fraud under the FCA (see Wang v. FMC Corp., 975 F.2d. 1412, 1420 (9th Cir. 1992)), there is often a fine line between what constitutes negligent conduct and what is considered reckless.

The Ninth Circuit Court of Appeals held that providers who bill Medicare have a duty to familiarize themselves with the requirements for payment (U.S. v. Mackby, 262 F.3d 821, 828 (9th Cir. 2001)). As a result, reporting in a manner clearly contradicted by statutory or regulatory payment provisions could lead to FCA liability. Where the violation pertains to a provision found in the Centers for Medicare & Medicaid Services’ (CMS) interpretive guidance, liability becomes less certain, and often turns upon whether the applicable provisions are found as a condition of payment or a condition of participation (see Mikes at 699-702).

For example, a qui tam FCA claim was brought against a physician’s group, Heart Doctors, based on the allegedly fraudulent billing of one of the Heart Doctors’ employed physicians. The facts of that case were revealed in subsequent litigation between the physician group, Heart Doctors, and the employed physician, Dr. Lane (Heart Doctors v. Lane, 2006 WL 2692694 (E.D.Ky. Sept. 13, 2006)). Dr. Lane allegedly was instructing nurses to provide chemotherapy procedures without the supervision of a physician, and then directing to bill Medicare as if the procedure had been performed in the presence of the physician. Heart Doctor’s apparently had no actual knowledge that this conduct had occurred; however, the qui tam relator brought the FCA case against Heart Doctors alleging that it recklessly permitted false claims to be submitted. Heart Doctors settled the FCA case for $434,180, and incurred over $100,000 in attorney fees.

Not only do hospitals and health care provider groups face substantial FCA liability as a result of the conduct of those that it employs, or with whom it contracts/associates, but a number of federal courts have held that there is no right to indemnification or contribution for FCA liability from either a co-defendant or from a third party where the indemnification claim is dependent on finding FCA liability by the party seeking indemnification. In other words, even if a single individual within the group is responsible for false claims, the group cannot recover the cost of defending itself and/or penalties from that individual.

As an example, Heart Doctors attempted to obtain indemnification from Dr. Lane because it was Dr. Lane’s conduct that led to Heart Doctors’ FCA liability. Citing a line of cases, the court in Heart Doctors found that a qui tam defendant cannot seek to offset their liability under the FCA through suits seeking indemnification or contribution from a third party. (See Mortgages Inc. v. U.S. District Court of the District of Nevada, 934 F.2d 209 (9th Cir. 1991); U.S. ex. Rel Madden v. General Dynamics Corp., 4 F.3d 827 (9th Cir. 1993)).

Prepare for the Perfect Storm of FCA Liability

Current and possible future conditions favor increased FCA liability for all health care providers.

As the economy worsens, physician payments are diminished, and patients — due to escalating co-payments and deductibles — avoid seeking physician services. These occurrences generally create a motive for physicians/groups to code services more aggressively.

Proposals in Congress may change provisions of the FCA to favor the qui tam relator and the government. See FCA Correction Act of 2007, S.2041 and Substitution S.2041, 110th Cong. (2007); FCA Correction Act of 2007, H.R. 4854, 110th Cong. (2007). These proposals include changes to the way that FCA damages are calculated, the addition of separate liability for the government’s costs of pursuing an FCA case, and elimination of the public disclosure original source rule that bars an FCA qui tam action where the qui tam plaintiff is not the original source of the information that leads to the filing of an FCA case. If these changes are enacted, it is anticipated that many more qui tam cases will be filed.

The Recovery Audit Contractor (RAC) program incents private contractors to find overpayments.

When combined, increased post-payment scrutiny, diminished barriers to filing an FCA case and potentially increased damages, and an incentive for more aggressive coding practices make a near perfect setting for substantially heightened FCA liability for any physician group, hospital, or other entity.

Take Steps to Limit Liability

Hospitals and physician groups make much better targets for qui tam relators (because they tend to have more money). As such, these entities must take deliberate steps to reduce FCA exposure due to the improper employee or contractor conduct. Specifically, employee and sub-contractor education in proper coding and documentation, as well as the relevant rules establishing conditions of payment, is critical. An effective internal audit program will not only identify errors before they get out of hand, but will demonstrate the entity’s efforts at compliance, thereby mitigating the potential that recklessness or deliberate ignorance can be shown.

The bottom line is this: Physician groups can be held liable directly for their own failure to prevent submission of false claims, as well as indirectly where the costs of defending such an action fall to the entity. Moreover, because indemnification is not permitted, hospitals and physician groups should consider stepping up efforts at minimizing FCA liability to preclude the possibility of such an action ever occurring. This may include reconsidering any budget reductions in the area of staff (physicians/coders) education and training, internal auditing, and compliance programs. Given the substantial amounts that can be recovered under the FCA, budget cuts in these areas may end up being “penny wise and dollar foolish.”

EMR documentation can create risky record keeping.

By Cheryl L. Toth

Documentation like the following is becoming more common as coding consultants audit practices that have moved to an electronic medical record (EMR):

• A 90-year-old woman who “denied pregnancy as a sign.”
• An infant with “good dentation.”
• The note for every female patient in a general surgery practice indicating a “full pelvic exam performed.”

“The overarching issue here is lack of visit template customization,” says Mary LeGrand, RN, MA, CPC, CCS-P, consultant with Chicago-based KarenZupko & Associates. “A critical component of EMR planning is customizing your visit templates—in addition to tailoring other elements of the system,” says LeGrand. “In most cases, you get little to no template customization help from the vendor. It’s up to a busy physician to do in his or her ‘spare time.’ And many practices fail to realize the importance of this step.” Read more »

When medical necessity drives documentation, optimal coding will result.

By G. John Verhovshek, MA, CPC

Aggressive claims review by government and private payers has brought a much needed spotlight to the shortcomings of medical documentation in support of optimal coding and reimbursement. This is a positive development, but what’s important to remember is that coding never should drive documentation. The idea, for instance, that “if only the doctor had documented one more bullet …,” even if well-meant, is wrong-headed. Rather, documentation rooted in medical necessity that accurately reflects the service level provided always will drive coding to the optimal level.

Let Physicians Document Completely from a Clinical Standpoint

“Optimize the medical record and the coding so that results do not depend on documenting anything extra,” advises Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting and a coding, billing, and compliance consultant. “It depends only that physicians better record what they are thinking and doing already.” In other words, a complete medical record results when physicians think and act as physicians—and document that process carefully—not by asking physicians to think or act as coders or auditors.

“Clinicians don’t evaluate patients in terms of bullet items or check lists,” Hammer notes. “The criteria are dynamic and vary from patient to patient depending on the nature of the presenting condition.” But a physician who captures his or her thought process (in determining the assessment and plan, as well as an appropriate history and exam) to arrive at a diagnosis and determine treatment creates a complete medical record that also yields optimal coding for the evaluation and management (E/M) service provided.

The medical record alone should be sufficient to recreate the circumstances of a physician/patient encounter (note that legibility plays a role here). Nothing pertinent to medical decision-making should go unnoted. If it’s important to the patient’s case, it should be in writing. “The documentation should paint a clear picture of ‘here’s what was found, here’s what was done, and here’s why,’” Hammer says. “Coders often say ‘not documented, not done.’ But if you as another clinician [or for instance, an auditor] are seeing the documentation for the first time, if something isn’t documented, you have to assume it wasn’t even considered.” Likewise, minimal documentation or inconsistencies within a note are of little clinical value, and create serious legal and/or malpractice liabilities.

Clinical Completeness Ensures Continued Quality Care

“I encourage physicians to think of the medical record first and foremost as a communication tool,” Hammer continues. “I ask, ‘If you were the next physician (whether as a partner or as a referral) to see this patient, what would you want/need the medical record to contain?’ This ensures quality and continuity of care for patients. Any physician should be able to look at any other physician’s notes and know not only the patient’s chief complaint at the prior visit, but also the documenting physician’s thought process in arriving at a diagnosis and treatment recommendations: What information was obtained from the history and exam? Which tests were ordered and why? Which drugs were prescribed and why? Are there co-morbidities or other pertinent factors? Complete documentation comes not from noting only what was done, but also why it was done.”

In other words, encourage your doctors to document completely not for coding, but for other doctors. Selecting an E/M service level is incidental to and should not compete with the goal of complete clinical documentation in the patient’s best interest. But one naturally will follow the other. The best documentation—from medical, legal, and coding perspectives—describes in some detail the physician’s clinical thought process. Many physicians undervalue this cognitive work, yet E/M service levels are intended to reflect not just of the extent of exam or history-taking, but the physician’s mental effort. In fact, documentation outlining the physician’s thought process in evaluating a patient’s presenting problem(s) (medical decision-making) drives and supports the extent of the exam and history.

In those cases when counseling dominates a visit, the physician should describe the encounter in sufficient detail to clarify what was discussed (for instance, what specific questions did the patient have? What was the physician’s recommendation?), why, and for how long. Again, the point is not to document anything additional or to dissect the encounter moment by moment, but only to describe what actually was done, for the benefit of other physician’s who may review the note at a future visit (and, ultimately, for the benefit of the patient).

Documentation of what was discussed, the education provided, etc., also helps the performing provider assess patient understanding and compliance. “So for instance, if the provider has counseled the patient multiple times on the same points, she can make the cognitive decision to change the plan due to patient compliance or lack of understanding,” Hammer says. “Not only does such documentation help other providers, it is also a good reference point for the performing provider.”

Pull Physicians Out of the “One More Bullet” Trap

Templates and electronic health records (EHRs) that use prompts to elicit “one more bullet” can be valuable tools to help physicians avoid minor oversights, but they also have a serious risk for abuse and for undermining the quality of documentation by focusing a physician’s attention on the wrong documentation issues. Remember: Coding based on documentation not warranted by medical necessity is a huge compliance risk.

Even the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, which essentially are coding instructions, insist on the primacy of clinical concerns, stating, “Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care.” Claims payment and submission are secondary and tertiary concerns.

The clinical examples contained in Appendix C of the CPT® manual don’t discuss bullet points or even the elements of exam and history. Rather, the examples rely primarily on the nature of the patient’s presenting problem and the presumed level of medical decision-making necessary to evaluate and treat a patient with that condition. It is up to the physician to document completely his or her cognitive work (including interpreting the information obtained from the history and physical exam to form an assessment and care plan) to support the service at the level described by any given example.

This isn’t to suggest that counting bullets is inappropriate to determine an E/M service level, or that E/M guidelines are illegitimate. Quite the contrary: Objective criteria are necessary to allow for consistent coding. But E/M documentation guidelines are coding tools, not clinical tools. Focusing on coding as the reason to improve documentation is putting the cart before the horse. Rather, what clinicians and coders alike must embrace is that the medical record is, first and foremost, a medical document. As such, physicians should be encouraged to improve documentation to improve medical outcomes. Those physicians whose documentation best supports optimal coding (and compliance) also are those physicians whose documentation best meets medical and clinical requirements, and whose documentation best describes his or her cognitive process during the E/M service. Such documentation naturally provides support (medical necessity) for services and procedures rendered, at the appropriate level.

Help Physicians See the Big Picture

“This issue is larger than simply E/M,” notes AAPC Vice President of Clinical Coding Content Sheri Poe Bernard, CPC, CPC-H, CPC-P. “If your physician isn’t documenting with enough detail for you to choose the correct diagnosis or procedure code, he isn’t documenting enough to withstand a malpractice suit or to understand in six months exactly what the condition and treatment of the patient was. This is a great approach to use when requesting more information from an under documenting physician: Not that you need it for coding (although you do), but that he needs to include it so that he is protected from any liability associated with under documentation.” There is nothing inherent to code selection—procedure, diagnosis, office visit—that shouldn’t be in the documentation for medical and legal reasons.

The bottom line: Documentation isn’t about coding, and it’s certainly not about bullets. Documentation always is about patient care. Coders who keep this in mind will have an easier time communicating with physicians about how to improve their documentation, from both clinical and coding perspectives. Encouraging physicians to do what they do best—provide the highest possible level of patient care and document accurately the cognitive work associated with that care—will create a win/win outcome for everyone.

A health care think tank says a gap exists between policymakers’ expectations that electronic medical records (EMR) can improve patient care and clinicians’ real-world experiences with EMRs. The study by the Center for Studying Health System Change was reported in HIT News.

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Physician office and hospital coding are sometimes two different worlds.

By Dorothy Steed, CPC-H, CHCC, CPC-I, CPUM, CPUR, CPHM, CCS-P, CEMC, CFPC, ACS-OP, RCC, RMC, PCS, FCS, CPAR

When physician coders/billers transition to a hospital environment, they frequently encounter difficulty without a clear understanding as to why. Hospital managers have positions to fill, but the required skill levels of hospital coders are often different from that expected of physician coders.

Know What Skills Hospital Coding Requires

To prepare for a physician coder/biller hospital position, you need to know the following 10 differences in the two work environments:

1. Physician coders are proficient in coding and billing specific services their physician group provides whereas hospital coders need reasonable proficiency in multiple specialty areas.

2. Hospital coders have to identify the principal diagnosis and properly sequence codes. In the hospital arena, the principal diagnosis is determined as the “reason, after study, that occasioned the admission.” When a patient has multiple co-existing conditions, the coder needs to identify the condition requiring inpatient admission.

3. Hospital coders must be able to select co-morbidities and major co-morbidities correctly. Medicare reimburses most hospitals based upon Medicare Severity Diagnosis-Related Groups (MS-DRG) methodology. Detailed physician documentation is critical in capturing these co-morbidities, which affect the hospital’s reimbursement. Very general statements regarding conditions without further details often do not equate to a complication/co-morbidity (CC) for reimbursement purposes. Other payers may reimburse on a slightly different methodology, depending upon the current contract, but the expectations of the coder are the same regardless of the payer. When diagnosis statements are lacking detail, the coder should query the physician for clarification.

4. The physician billing form contains only four fields for diagnosis codes; whereas a hospital coder commonly selects 10, 15, or 20 diagnosis codes. Whether all will fit onto the UB-04 is not relevant. Due to the collection of disease data reported by hospitals, it is necessary for hospitals to capture all codes for applicable conditions that require physician management or affect the physician’s management of the patient.

5. Inpatient coders must report the correct Present on Admission (POA) indicator for conditions managed during the inpatient admission. The purpose of the POA indicator is to report whether a condition was present at the time of the inpatient admission order. Conditions such as catheter-related infections that occur during the admission may not generate additional revenue for the hospital even though they use additional resources to treat the hospital-acquired condition.

6. CPT® codes are not reported on hospital inpatient claims. Procedures are reported using codes from ICD-9-CM’s Volume 3. These codes are not a direct crosswalk to CPT®; often, when a CPT® code describes multiple steps, more than one code from Volume 3 are required to describe the procedure adequately. For example, 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) describes both cataract extraction and intraocular lens implant. Volume 3 will require that two codes be reported; one for the cataract extraction (13.3 Extracapsular extraction of lens by simple aspiration (and irrigation) technique; Irrigation of traumatic cataract, 13.41 Phacoemulsification and aspiration of cataract, or 13.43 Mechanical phacofragmentation and other aspiration of cataract, depending upon technique), and a second code for the lens implant (13.71 Insertion of intraocular lens prosthesis at time of cataract extraction, one-stage).

7. In general, hospital coders are required to meet both productivity and accuracy standards. For example, they may be required to process inpatient records in an average of  18 to 20 minutes each; ambulatory surgery records, eight-10 cases per hour; emergency department (ED) records, 20 per hour; diagnostic referrals such as lab and radiology, 30 per hour. Standards for accuracy are likely to be in the 92 to 95-percent range (this is up to the coding manager, but most require accuracy well into the 90 percent range).

8. Charges are entered onto a hospital claim through a charge master, which is a large file containing all services, supplies, and drugs the hospital uses to treat the patient. Departments providing services to the patient are responsible for their services’ charges, and these appear on the UB-04 under the revenue codes applicable to the area in which the service was provided.

Hospital billers need to view the charges, determine if errors are present, and have any errors corrected prior to releasing the claim to the payer. Common errors include incorrect units reporting and missed charges.

Operation room (OR) time and anesthesia time are typically reported in 15 minute increments by the hospital. For example, reporting of 4 units = patient in OR for one hour. The number of units for OR and anesthesia should either be the same, or there should be no more than one anesthesia unit more than OR units (to allow for sedation to begin a few minutes prior to the start of the surgical procedure). More than one unit should be considered an error requiring the biller to correct the charges.

9. Although similarities exist between physician coding and hospital outpatient coding, hospital staff needs to understand and correctly use the facility modifiers:

• 27 Multiple outpatient hospital E/M encounters on the same day
• 73 Discontinued outpatient procedure prior to anesthesia administration
• 74 Discontinued outpatient procedure after anesthesia administration

Medicare outpatient reimbursement for most hospitals is based on Ambulatory Payment Classifications (APC) rather than the physician fee schedule or Resource-Based Relative Value Scale (RBRVS), and managed care payers also may reimburse on a form of APCs.

10. Understand that hospital coding managers may not have the option to staff based on just outpatient coders. Although it is relatively common for the most experienced coders to handle the inpatient claims, when short staffed or during vacation time, all staff is expected to assist in completing the work. Likely, there will be a time when you need to code inpatient claims.

Weigh Your Skills Against Hospital Expectations

If your goal is to transition into the hospital environment, review your skills against these requirements and determine your readiness for change. Many coding/billing managers in large urban markets hire only those applicants who demonstrate skills in at least some of the 10 listed areas. Be realistic as to what your current skill level is and how it can be utilized by a hospital. When you think you are ready to take that leap, consider the fact that there are generally more employment opportunities in rural locations due to the shortage of qualified coders in remote areas. Also, consider that managers will usually require you to take a pre-employment test applicable to their needs, regardless of geographical location. If you score well, you have a good chance of being the selected candidate.

Correct coding relies on ICD-9-CM diagnosis assignment and sequencing.

By Melissa Fincham, CPC, CPC-H

Diagnosis code sequencing can become a nightmare when wading through all the available coding and regulatory guidance. You can simplify the process by differentiating reimbursement policies set forth by your fiscal intermediary (FI) or Medicare administrative contractor (MAC) from the guidance provided by coding authorities — namely American Hospital Association’s (AHA) Coding Clinic.

FIs and MACs have developed countless policies providing specific instructions to allow (or disallow) coverage for tests and procedures. These policies often include requirements for specific CPT® codes, frequency limitations, documentation, and accepted diagnosis codes/code sequence. The AHA has published coding policies serving as the general “rule of thumb” when coding services, regardless of the medical insurance coverage the patient has. The collision of these two worlds is not pretty, and often leaves coders confused as to which advice to follow. For example, let’s consider the Medicare hospital outpatient perspective for screening and diagnostic colonoscopy encounters.

Important! This information is specific to hospital outpatient reimbursement, for Medicare claims submitted on the UB-04 claim form. National Medicare guidelines for physician billing differ from those discussed here. For physician billing rules regarding screening vs. diagnostic colonoscopy ICD-9-CM code sequencing, see Medicare Learning Network Matters SE0746, “Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscopy,” which may be found on the Centers for Medicare & Medicaid Centers (CMS) Web site: www.cms.hhs.gov/MLNMattersArticles/downloads/se0746.pdf. Private payers may stipulate different guidelines.

Look to AHA Guidance for Code Assignment

First, let’s review AHA guidance:

• AHA Coding Clinic, 4th quarter 2001 advises assigning code V76.51 Special screening for malignant neoplasms; colon as the first-listed code when a patient without a personal history of gastrointestinal disease and without signs and symptoms has a screening colonoscopy, even when the colonoscopy reveals a polyp or other abnormality.
• AHA Coding Clinic, 1st quarter 2004 advises assigning code V76.51 as the first-listed code when a patient presents for a screening colonoscopy. Even if the screening exam is converted to a “surgical” colonoscopy (i.e. polyp removal), the fact remains that the patient initially presented for a screening.

LCDs Show Guidance Inconsistency
Review of Local Coverage Determinations (LCD), however, often reveals different guidance. The confines of this publication don’t allow us to go through the LCD requirements from all FIs and MACs, but we can address specific guidance provided by National Government Services (NGS), a Medicare contractor, to get a general idea.
NGS has two LCDs which pertain to colonoscopy:

• Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy (L26404), revised Oct. 1, addresses requirements for colonoscopy other than those done for colorectal cancer screening.
• Colorectal Cancer Screening (L26402) deals specifically with screening exam — that is, no signs, no symptoms, and no chief complaint. In addition to reading the LCD, it’s important to read the supplemental instructions articles (SIA) associated with the LCD, which often contain valuable coding guidance. This is true for any LCD policy you review.
Per NGS’ policy, V76.51 should be the first-listed or principal diagnosis for screening colonoscopy, followed by incidental findings, such as hemorrhoids and diverticulosis. If, however, during the screening exam a polyp is discovered and removed, the exam is no longer considered a screening. Here’s where coding directives under the Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy LCD come into play. Diagnosis code V76.51 is not listed in this LCD as a “covered diagnosis.” This means NGS will not accept V76.51 for colonoscopies that are diagnostic or surgical in nature.

To apply these guidelines, let’s look at a few real-world examples from a hospital outpatient services perspective:

Example 1:
The patient comes in for screening colonoscopy (no indication for high-risk screening). During the exam, a polyp is discovered in the transverse colon and is removed via snare polypectomy. No other abnormalities are noted and the patient is instructed to follow up in two years, pending pathology results. Pathology reveals adenomatous polyp, transverse colon.

ICD-9-CM Diagnosis Code Assignment Using AHA Coding Clinic Guidance
Principal Dx: V76.51
Secondary Dx: 211.3 Benign neoplasm of other parts of digestive system; colon

Remember, according to AHA Coding Clinic, screening diagnosis V76.51 should be the first listed diagnosis code with the finding of “polyp” listed as a secondary diagnosis.

ICD-9-CM Diagnosis Code Assignment Using NGS LCD Guidance
Principal Dx: 211.3

Example 2:
A patient presents with generalized abdominal pain off and on for three weeks. The physician performs a colonoscopy to evaluate and, if necessary, treat the patient. The colonoscopy reveals no abnormality; the cause of the abdominal pain is unknown. Patient is instructed to follow up in the office.

ICD-9-CM Diagnosis Code Assignment Using AHA Coding Clinic Guidance
Principal Dx: 789.07 Other symptoms involving abdomen and pelvis; abdominal pain, generalized
ICD-9-CM Diagnosis Code Assignment Using NGS LCD Guidance
Principal Dx: 789.07

This example is considered a screening exam although no abnormality was discovered. The patient still presented with the complaint/symptom of “generalized abdominal pain.”

This next example is a little trickier, and shows you the application of the recent update to NGS’ Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy LCD.

Example 3:
A patient underwent treatment for colon cancer two years ago. Her most recent colonoscopy was last year. It is time for her repeat colonoscopy for cancer surveillance and follow-up. Colonoscopy was performed to the cecum without difficulty. Slow withdrawal revealed no abnormalities.
ICD-9-CM Diagnosis Code Assignment Using AHA Coding Clinic Guidance
Principal Dx: V67.09 Follow-up examination following other surgery
Secondary Dx: V10.05 Personal history of malignant neoplasm; large intestine
ICD-9-CM Diagnosis Code Assignment Using NGS LCD Guidance
Principal Dx: V67.09
Secondary Dx: V10.05

According to NGS’ LCD revision, effective Oct. 1, V67.09 should be used as the principal diagnosis when the patient has a history of colorectal cancer or polyps and is being followed for that reason. Prior to Oct. 1, this was the case only for the first year after the patient’s initial treatment; the revision, however, removed the phrase “the first year.”

The policy also requires that one of the following ICD-9-CM codes be listed as a secondary diagnosis: V10.05, V10.06 Personal history of malignant neoplasm; Rectum, rectosigmoid junction, and anus, or V12.72 Personal history of diseases of digestive system; Colonic polyps. Take note of the phrase “… and is being followed for that reason.” This indicates that this guidance would not apply if the patient is presenting for some other reason.

This guidance for V67.09 use is in line with advice in AHA Coding Clinic issues published first quarter 1995 and third quarter 2002.
Let’s examine in the following example how the diagnosis assignment changes when the intent behind the exam is altered.

Example 4:
A patient underwent treatment for colon cancer three years ago. Since then, she has done well and has had no problems. She presents today for her regular screening colonoscopy. Her last exam was two years ago. A scope was performed in the cecum without difficulty. No abnormalities were found; and the patient was instructed to repeat the colonoscopy in two years.

ICD-9-CM Diagnosis Code Assignment Using AHA Coding Clinic Guidance
Principal Dx: V76.51
Secondary Dx: V10.05
ICD-9-CM Diagnosis Code Assignment Using NGS LCD Guidance
Principal Dx: V76.51
Secondary Dx: V10.05
In this case, V76.51 is appropriate under NGS guidelines because the patient is being seen for purposes of a screening exam and not specifically for follow-up evaluation of the cancer.

AHA Coding Clinic is the official source for ICD-9-CM guidance, and should be followed unless otherwise specified by your FI/MAC or CMS.

Remember: When coding Medicare services, guidance published by CMS and its related entities (i.e. FI/MAC) takes precedence and is the key to accurate code reporting and sequencing. It is necessary to follow their guidelines to ensure proper claims submission and reimbursement for the services provided.