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Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
Don't the doctors know the rules? That's the question being asked by ASCs these days because a number of claims are still being denied due to the facility billing a diagnostic colonoscopy while the physician bills a "screening" colonoscopy.
The most common occurrence of this happening is when the patient has symptoms such as rectal bleeding, occult blood, diarrhea or abdominal pain. The ICD-9 coding guidelines specifically state, "Screening is the testing for disease or disease precursors in seemly well individuals so that early detection and treatment can be provided." This is what translates into what we call an "asymptomatic" patient or one that presents with no symptoms. When the patient has any of the above listed conditions or any symptoms for which a colonoscopy is performed to determine the origin of those symptoms, then it is a diagnostic colonoscopy and not a screening. Too many times, you will see an op note with a diagnosis that indicates rectal bleeding and screening for colorectal cancer, and the indications will be that the patient has never had a screening procedure.
It does not matter that the patient has never had a screening colonoscopy. This is not the criteria used when determining medical necessity for colorectal cancer screening procedures. When the patient presents with symptoms, the procedure is considered diagnostic. Part of the misunderstanding starts with a patient who may know that with their policy they don't have a co-pay or deductible for screening procedure, and they have never had a screening, so they want the service billed that way because it means no out-of-pocket expense for them. Unfortunately, they don't understand or know the guidelines that must be met in order to determine when a screening can be performed. This is where education becomes key.
There are a couple of opportunities for the ASC to avert the irate patient phone call that comes after the procedure has been performed and the patient has received a bill -- because at this point, it will be hard to reason with them and explain the difference in coding.
1. The scheduler should be the first line of defense. When the physician's office calls to schedule a screening colonoscopy the first question should be, "Does the patient have any symptoms?" If the answer is yes, then inform the office that this does not qualify as a screening procedure.
2. Perform verification of benefits. While you have the insurance company on the phone, this is an excellent time to confirm whether or not the patient meets the coverage requirements and is eligible for a screening.
3. Notify the patient. Make them aware of any financial responsibility, and make sure they understand that when they have symptoms a screening colonoscopy will not billed regardless of the fact that they have never had a previous screening procedure. If necessary refer them back to their insurance carrier for further explanation but make absolutely sure that you are on the page with the provider before the service is performed.
Effective communication is important in ensuring claims payment and overall well-being of the patient.
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