Discovered During Screening

October 1, 2007

We are a gastroenterology group that schedules many screening colonoscopies. Of course, there is a possibility that a polyp or lesion may be removed at the time of the procedure, if found. We have always been told to bill by the diagnosis or reason for the procedure. An example would be if a patient was scheduled for a screening colonoscopy but a polyp was removed at the procedure, we would then bill the colonoscopy and link it to the diagnosis of a colonic polyp and the secondary diagnosis would be a screening colonoscopy. Some insurance companies are now telling me that if a patient is scheduled as a screening colonoscopy, then that should always be the primary diagnosis no matter what is found during the procedure. Any additional findings such as the polyp removal would be listed as the secondary diagnosis. Can you please shed some light on this situation? We do not want to have to deal with fraud, but our patients are getting very upset because the insurance companies are stating that we are billing incorrectly.

Question: We are a gastroenterology group that schedules many screening colonoscopies. Of course, there is a possibility that a polyp or lesion may be removed at the time of the procedure, if found. We have always been told to bill by the diagnosis or reason for the procedure. An example would be if a patient was scheduled for a screening colonoscopy but a polyp was removed at the procedure, we would then bill the colonoscopy and link it to the diagnosis of a colonic polyp and the secondary diagnosis would be a screening colonoscopy.

Some insurance companies are now telling me that if a patient is scheduled as a screening colonoscopy, then that should always be the primary diagnosis no matter what is found during the procedure. Any additional findings such as the polyp removal would be listed as the secondary diagnosis. Can you please shed some light on this situation? We do not want to have to deal with fraud, but our patients are getting very upset because the insurance companies are stating that we are billing incorrectly.

Answer: This response was provided by Sheri Poe Bernard, of the AAPC:

The answer is found in the ICD-9-CM Official Coding Guidelines for Coding and Reporting, 18.D.5: “Should a condition be discovered during the screening, then the code for the condition may be assigned as an additional diagnosis.” The insurance companies are right: First, report the screening diagnosis. This communicates to the payer that the scope was scheduled. Secondarily, report any findings from the screening, as in the case of polyp. Remember, though, not to report diagnostic and procedural scope codes for the same session. Once a therapeutic measure is taken, the procedure is no longer a “diagnostic” scope, and the appropriate CPT code for the therapy should be selected.