All right. So, welcome back. Oh, yes. And now to the never-ending GI discussion. Screening versus diagnostic colonoscopy. I'm going to tell you, it's crazy. You would think that this should not be an issue anymore for as long as we've been dealing with this, but I'm going to tell you, it is. So, all right. So, we're going to talk about 11 things in here. First of all, we'll talk about the Affordable Care Act in more detail. We're going to talk about Medicare screening colonoscopy loophole, defining what average risk screening colonoscopy is on the different options and high risk and diagnostic, and screening versus diagnostic for IBD patients, and obviously some screening modifiers. And we've already talked a little bit about the visit before screening, but we're going to talk about that again. And then last but not least, the False Claims Act. So, the current Affordable Care Act policy, published on May 18th of 2021, really did not become finalized in effect until May 31st of 2022. And when it was published on May 18th of 2021, the task force is recommending that screening start at age 45, and it's screening all adults 45 to 75 for colorectal cancer, and several recommended screening tests are available. All right. So, there's three grades. Grade A includes adults age 50 to 75, grade B is adults age 45 to 49, and grade C is adults age 76 to 85. And you need to look for payer policies to address all grades for coverage. So, remember, this is Affordable Care Act. So, it is enacted by our commercial payers, right? Medicare adopted part of the Affordable Care Act policy and began coverage at age 45 on January 1st of this past year. That grade C on the adults age 76 to 85, this is where you're actually going to have to look at individual payer policies on this. Some payers automatically cover it, most do not. And then some also say that it will be included based upon the payer and the provider's recommendations. Of course, it has to deal with the patient's, let's put it this way, clinical status, and how healthy they are. All right. So, we kind of already talked a little bit about this as well. The ACA update on follow-up colonoscopy after positive stool-based screening studies. So, again, as of May 31st of 2022, the ACA plans have to provide coverage without cost sharing for anybody that has a positive screening stool study. And then most payers accept the G code, G0121, and we'll talk a little bit about that more in detail. And then Z1211, of course, is your diagnosis code for average risk colon screening. And R19.5 is your diagnosis code for the positive stool studies. So, remember that we still don't put the Z code in the first position. Remember that primary diagnosis code is the one that supports the medical necessity. So, since the payers are still allowing a screening benefit with the Z code, all right, we want to make sure to put that primary in the R19.5 in the second position. All right. So, this is a little bit of the Affordable Care Act. And I think a lot of times we tend to forget this. We try to forget this. But the thing is, is this little statement that in the highlighted yellow is important and that you explain this to your patients. All right. So, the preventive task force guidelines apply to routine screening. All right. So, it says the recommendation applies to asymptomatic adults 50 and older. Now, of course, that has now been adjusted to 45 and older who are at average risk of colorectal cancer and who do not have a family history of known genetic disorders that predispose them to high lifetime risk of colorectal cancer, such as Lynch syndrome or FAP, a personal history of IBD, a previous adenomatous polyp, or previous colorectal cancer. When screening results in the diagnosis of colorectal adenomas or cancer, patients are followed up with a surveillance regimen and recommendations for screening no longer apply. All right. So, again, this is such an important little paragraph, all right, that a lot of our patients are not aware of. All right. And we, you know, the thing is, is the payers that they, you know, patients call the payers and say, okay, why do I have to pay any money? Because they had a history of polyps. All right. And of course, the payer responds back and says, well, if the doctor coded it with screening, it would have been covered at 100%. Well, yeah, we could have put that diagnosis code on it, but it would not be appropriate. Now, you have to remember that payer policies, their national policies and the plan policies may differ. So, some of the patient's plan policies may cover the history of polyps or the history of cancer, but their national policies in writing on their websites pretty well back this highlighted paragraph up. All right. The Medicare screening colonoscopy loophole. All right. So, this is actually was published and signed into law on December 27th of 2020. And it took them a while to update this in the Medicare carriers manual until November of 21. So, what happens is this closes a loophole for when screening colonoscopy becomes a diagnostic procedure. And I don't know, you know, for all of that you listening in, some of you may not have been aware of this, but for Medicare, if during a screening colonoscopy, you remove a polyp or do a biopsy or anything like that, it changes the patient's benefits. All right. So, it becomes a surgical procedure and it falls out of that screening colonoscopy benefit. And so, anytime that you do any type of surgical procedure during a screening on a Medicare patient, then what happens is the patient is responsible for the percentage that Medicare does not pay. All right. So, your standard diagnostic or surgical benefit is that Medicare approves now for normally approves 80 percent and the patient is responsible for the 20 percent that Medicare does not pay. But that has changed for the screening loophole. So, beginning this past January 1st, the patient now is only responsible for 15 percent and CMS or Medicare pays the 85 percent. And then in 27, it goes to 90-10. And finally, in 2030, the patient doesn't have any out-of-pocket responsibility. All right. If during that procedure, a polyp or lesion is found, that would be covered at 100 percent. All right. But up until that point, the patient does have cost sharing with us. Now, I think we pretty well all know that a good percentage of most of our, I would say, a majority of our Medicare patients have a secondary policy or they have a Medicare Advantage plan, which pretty well covers that cost sharing. But if they don't, then they would be responsible for that 15 percent that Medicare does not cover. There's a modifier, and I'll talk about that in just a little bit, that we put on a screening converted to a diagnostic or surgical procedure that waives the patient's deductible. And that's the PT modifier. So, if you want to know, and if you actually want to see the bill that was signed, then there's the link on this slide, and you go to page 2175. It's a huge bill. All right. So, let's talk about the difference between screening versus surveillance versus diagnostic colonoscopy. So, the definition of screening is lack of symptoms and abnormalities. And the patient's eligible for screening by most payers after age 45. There are still some what's called grandfathered plans out there where the patient does not have preventive benefits. All right. And in that case, it's not going to be covered for that patient. But the majority, and you would think the grandfathered policies, and actually when this was the screening colonoscopy rule, the Affordable Care Act was published in 2010. All right. And they basically said that grandfathered plans would only be out there for three years. Well, they're still out there. And so, it seems like the grandfathered plans apply to more like unions, locals, some school districts, et cetera. But again, most of them now do cover screening and preventative benefits. Medicare covers that 100% for screening colonoscopy with no patient financial responsibility, as long as all you do is look in that touch. All right. And this is allowed once every 10 years by Medicare. Now, we just talked about this. If during the screening procedure, polyps or lesions are found, the procedure is now considered a surgical, which often can increase the patient's financial responsibility, even though the intent was screening. So, if it's billed with screening as a principal diagnosis and the finding is a secondary, most payers will continue to pay the preventive benefits. All right. Now, we know that some of the payers just want the findings, because if you put the modifier 33 on the surgical, it pretty well tells them that it was a preventive service and that they don't want screening in the first position. But this is, you know, and we'll probably be, you'll probably get tired of us saying this, but you need to create a spreadsheet by payer for certain things and screening is one of them. So, you know, for this payer, if we do a screening and we convert it to a surgical, what diagnosis goes in the first position, what's in the second, et cetera, and what modifier do we need to attach to this? We know that a lot of our Medicare payers, if you put the PT modifier on that claim, they don't want screening in the first position, they want the findings. So, again, which goes first? It's like, which goes first, the chicken or the egg? So, anyway, for Medicare, modifier PT is added and it waives the patient's deductible, but the patient's now responsible for the 15% co-pay. For the commercial payers, we attach the modifier 333, which should still trigger preventive benefits. We deal with a lot of clients through Ask Miller, okay, and I think most of the times what we've been hearing is we still have some payers that even with the 33 modifier, that they don't want to end up paying that at 100%. You know, it's like, what did we do wrong? Well, again, you have to know where the patient's plans are. All right, so making sure that you verify eligibility, a good percentage, and I think we all know that a good percentage of screening colonoscopy does end up in pilot removal, right? And that's the whole purpose of it. We want to find something before it turns into malignancy, you know, so we definitely want to make sure to see what patient benefits are. So, what is surveillance and why do some carriers not cover it as a preventive benefit? So, surveillance is considered an endoscopic exam to identify recurrent neoplasia in an asymptotic individual, and that's the key, asymptomatic, with a previous identified precancerous lesion. All right, and also surveillance applies to patients with previous cancer. So, I think you all know that adenomatous polyps or adenomas are polyps that grow on the lining of the colon, and they do carry a high risk of cancer. So, the adenomatous polyp is considered premalignant, and if left untreated, it is likely to develop into a colon cancer. The other types of polyps that can occur in the colon are hyperplastic and inflammatory, and I mentioned this before, that inflammatory polyp, when you look in the ICD-10 book and you type in inflammatory polyp, or you do, for those of you that have coding software, and you type in inflammatory polyp, it leads you to K51.4, and that is a patient with ulcerative colitis with pseudopolyps and inflammatory polyps. So, just don't automatically rely on the index. All right, so you're not going to assign that K51.4 on somebody that does not have ulcerative colitis, but they just have an inflammatory polyp. And if you're unsure, who do you ask? You ask your doctor, all right, should, you know, this patient has an inflammatory polyp. An inflammatory polyp, if this is a patient that does not have IBD, most likely is nothing that's going to be or require further surveillance in patients eligible for another screening in 10 years. But again, if you have any questions, you ask your doctor. All right, the ACA, which commercial insurance follows, you know, left a loophole which specified a screening regimen is every 10 years in surveillance as anything less. So, Medicare does not follow the ACA on this. Medicare will cover a history of polyps. They'll cover a history of cancer, all right, under their surveillance benefit and or preventive benefits. So, again, you know, the payers follow Medicare when it's to their benefit. So, surveillance colonoscopy, again, patient is asymptomatic. They have a personal history of colorectal cancer, amniotic polyps, are inflammatory bowel disease. Many commercial insurance carriers and Medicare replacements do not cover under a screening benefit. And you would think that Medicare replacements should follow Medicare guidelines. The majority do, but you have to definitely check for that. All right, so I hope most of you do pre-authorization on colonoscopies. And I think for the, we've had some issues with UnitedHealthcare proposing that did not go into effect, that they were proposing that all colonoscopies had to be pre-authorized, you know, and they give you a whole laundry list of approved diagnosis codes for diagnostic colonoscopies, et cetera, but it did not go into effect. However, you still have to call, make sure that the patient's eligible, et cetera, to make sure that what their benefits are. You know, I know some of you don't do this, but if you leave this to the patient to do, and I know a lot of times it's on your policies and you make sure that the patient understands, it's up to the patient to double check. I had a EUS earlier this year and I was told it was my responsibility to do a double check on this, you know, even though I knew that the physician's office was going to do that as well. All right, I know my benefits, but a lot of patients do not know their benefits. All right, so making sure that you tell the patient, especially if they have esoteric polyps, that your payer does not consider this a preventive benefit and you will be responsible for this amount. All right, so we know that Medicare covers surveillance 100% for G codes and a 15% copay of polyps are removed. Now, some carriers do cover G0105, and that is the code for high-risk screening, as Medicare calls it, or surveillance for their commercial payers as a preventive. And again, that is going to be, you're going to find that out when you verify eligibility for that patient. There's two steps, pre-authorization and eligibility. Pre-authorization, the last thing that you get told most of the time is that pre-authorization is not required as long as the patient is outpatient, and that's something you also need to double check. Where are you going to do this patient's procedure? All right, so an outpatient is considered an AFC, all right, or your office. An outpatient at the hospital is not the same, all right, and we're seeing a lot of payers not wanting to pay for outpatient services, all right, in the hospital setting unless the patient is actually ASA4 status, or if your ASC does not have the equipment to perform this procedure that you're planning on doing. All right, so screening versus diagnostic for IBD patients. Do patients with IBD, Crohn's or ulcerative colitis qualify for high-risk screening? All right, it's a yes and no situation. So if the provider proceeds under the same guidelines as a routine screening, you're not planning on taking biopsies. You're viewing the colon and only biopsying abnormal appearing tissue, then yes, this would be billed as screening. It would be billed as a GO105, all right, and for the payers that don't accept GO105, you could bill this as 45378 with the 33 modifier. However, often the intent to proceed with the procedure is to randomly biopsy the colon to assess how the patient's biologics or medications are keeping the disease under control. That is considered diagnostic. That is not screening, and so random biopsies are never taken during a screening colonoscopy. So random biopsies indicate that the provider's intent for the procedure is diagnostic. So if the IBD patient questions whether a colon will be billed as screening, you need to check with your provider and determine the intent, and I think the majority of your physicians and providers will say, oh yeah, I'm going to be taking biopsies. So then it would be considered diagnostic. All right, so a diagnostic colonoscopy is a patient that has symptoms or other abnormalities prompting evaluation of the GI tract. We're talking about diarrhea, we're talking about hematochezia, we're talking about abdominal pain, change in bowel habits, weight loss, anemia, an abnormal x-ray of the GI tract. Now this is not all of them, but these are, you know, somebody that's symptomatic and they have an abnormality. You cannot have a symptom and screening. That is completely contradictory. So let's talk about the actual procedure codes. G0121 is a colorectal cancer screening on an individual not at high risk and is to be used for colonoscopies for individuals at low risk of screening. It's covered at once every 10 years, at least 119 months from the last screening, and the only diagnosis code submitted is Z1211. Remember, the good percentage of your commercial payers also accept these codes, and the reason why you want to do these codes is there's no out-of-pocket for the patient. All right, so primarily Medicare on G0105, and this is high risk screening, is to be used for colonoscopies for individuals at high risk screening. It's covered once every two years, at least 23 months from the last screening colonoscopy for those at high risk, and the only code submitted that starts the time clock is a G code, and I think that's a common question that we get. So our doctor did a screening colonoscopy and removed a polyp, and now they want to bring the patient back in a year to look at that area. All right, well, we can't do that. Well, actually, yes, you can, because there's no time interval on a surgical procedure. So the only thing that actually starts the time clock is a G code. Just because you put a PT modifier does not start the time clock. All right, so again, are the Z codes, right? So it's only thing that starts that time clock is a G code. All right, so here's UnitedHealthcare's policy on personal history of adenomatous polyps. Remember what I said that you need to look on the individual payers' websites to find out what their policies are? All right, so most of the national policies out there, Cigna, United, Aetna, Humana, just to name a few, pretty well follow this guideline. So it says, if a polyp is encountered during a preventive screening colonoscopy, are future colonoscopies considered under the preventive care benefit? And their answer is no. If a polyp is removed during a preventive screening colonoscopy, future colonoscopies would normally be considered to be diagnostic because the time intervals for between future colonoscopies would be shortened. And remember what I said earlier about the patients calling in and saying that if you coded this correctly, it would pay out? This is your ammunition, guys. We need to make sure that we follow the guidelines for the payers. All right, if we try to get a little creative and try to get that patient their preventive benefit, remember that primary diagnosis that you put on the claim is what triggers the patient's benefits, all right? You know, we can get into trouble, right? And a lot of times, this is what we've been hearing by the practices, that we got paid on this, patient didn't have any out-of-pocket, we build the Z1211 in front of Z86.010, and the patient had no out-of-pocket. Well, yeah, because they looked at the Z1211 first in front of Z86.010. And so it seems, you remember that the insurance companies also have outside auditors come in to make sure that they are paying their policies and their claims appropriately. And this is kind of what happens is that they start looking at this. They don't just look at the primary. They look at the secondary and go, huh. Well, this patient's plan does not have a rider on it that allows for this to be paid at 100% with a history of polyps. So guess what? We're going to recoup the money. All right. So again, remember that we want to bill it accurately based upon the patient's benefits. All right, screening modifiers. The PT and the 33 we kind of talked about already. We want to know which one you use is carrier specific. It's not used on G codes because the definition of a G code already includes a screening issue. So modifier PT is for screening turned diagnostic. It waives the patient's deductible, although they're responsible. Sorry, it's not 20%. It's the 15% copay. The 33 modifier, all right, if you would bill to the carriers that don't accept the G code, it also triggers the preventive benefit for the patient. The modifier 52 means that you pass the spleen flexure but did not reach the cecum and you removed a polyp. You did some type of therapeutic procedure. All right, usually it's a poor prep and you're going to usually plan to repeat it at some point. Now, for Medicare reimbursement, the modifier 52 usually gets paid at 100%, I'm sorry, not at 100%, at 50%. All right, but that's Medicare. If you're looking at the commercial side, most of them will review the claim, look at the documentation and medical record to determine what payments that you're going to get. The modifier 53 is for an incomplete screening colonoscopy, which means all you did was look and not touch. You did not reach the cecum. And the modifier 74 is not the physician charge. It goes on the ASC charge when the doctor bills the 53 modifier. So some of the issues that we encounter with screening, and I think we pretty well talked about this a couple of times already, is you were supposed to bill the screening. All right, so one of the things that we don't automatically assume, you know what assume means, that the patient is incorrect. We may find out that the patient's carrier does allow the screening diagnosis to be billed primary with a history of polyps in order to process that are preventive. You should have found that out at the time of preauthorization when you check for eligibility. Make sure that the policy, though, has this information in writing. And this is not the case for the majority of payers. You really want to have that in writing to make sure that you billed it correctly. We all make mistakes, remember. Sometimes this happens. So you want to let the patient know that you will have the chart reviewed. And it's possible, too, that the wrong information was entered into the colon report. The patient has a family history of polyps, but personal history was entered. And it seems that family history really does not cause as much as a problem with this. Most of the time with family history, the preventive benefits will still be covered. The patient is called insurance. Rep was told if you resubmitted a screening, it would be covered. Yeah, we hear this all the time. So if the patient does not like your explanation and feels you should still billed it incorrectly, they need to initiate a visit or an encounter between you, the patient, and the claims rep. Most of the time when the patient calls the insurance company, they do not talk to the claims rep. They talk to the first person that's trying to get the patient off the phone and basically just say that, oh, the doctor coded it wrong. So what about the patient who's symptomatic, but that isn't why we are doing the colonoscopy? So it is up to your doctor or your provider to identify the medical necessity for any procedure. If the patient has a symptom, but that is not why the colonoscopy is being ordered, then that needs to be documented in the visit note. And so what happens is sometimes the payer doesn't just look at your endoscopy report. They actually want to see your visit note. And also, guys, remember that the payer is looking at a claims history, a paid claims history. And what happens if this patient's been treated by primary care for GI conditions, and all of a sudden you follow up with the screening colonoscopy? Sometimes that is also what triggers them to look at your claims. So example, chronic constipation currently being managed by Miralax and Diet does not require an endoscopic exam. And this is what actually should be documented in your record. Patient's eligible for screening, and this will be scheduled. So you are identifying the patient does have a GI complaint, but you're managing it, and that is not why you're doing this endoscopy. We all know that chronic constipation is not an indication for colonoscopy. But if this is a change in bowel habits, yeah. So it's up to you to expand on the patient's symptoms and conditions. The other one is intermittent abdominal pain due to known history of IBS. No endoscopic evaluation is indicated. Patients should be scheduled for screening colonoscopy at their convenience. And so for both of these examples, the only indication on the colonoscopy report should be screening. So this is something that you really need to make sure that your schedulers know. So before they even schedule something at the ASC, or say for the hospital, and if they see that there's screening in a symptom, they should be stopping that right there and going back and going to the provider and say, whoa, wait a minute. Hold on. This is contradictory. We want to make sure and iron it out so that there's no issues with this. All right, so biopsies rule out microscopic colitis for screening. So remember that screening means no symptoms. So why are biopsies done on normal mucosa? I'm going to be talking about that a little bit too on the EGD side as well. But guys, sometimes when we're looking through those endoscopy reports, it says screening. And then you look through the body of the endoscopy note. And the colonoscopy is done. And there's no abnormalities found. But biopsies were done to prove on microscopic colitis. And it just triggers the alarm in my brain. It's like, oh my gosh, this is non-screening. All right, so why are you doing biopsies on normal tissue with no symptoms? So if medical necessity is not documented, this is considered a potential abuse situation. We do have to worry about this. Also, the pathologist needs a reason for the specimen. It's like, OK, wait a minute. It's normal, but they sent me a biopsy. So what's going on here? And a lot of times, we all know the majority of these come back as normal. There is no colitis, et cetera. So what's the pathologist going to assign? Because that makes no sense. Screening usually is not an appropriate indication for pathology services. All right, so our question. What modifier is added when the scope was unable to get beyond the hepatic flexure due to a poor prep? Is it modifier 22? Is it modifier 53? Is it modifier 52? Or is there no modifier necessary on this claim? Oh, OK, we're almost at 50-50 between 53 and 52. OK, and it could be one or the other because this question was really not as specific as you probably needed. All right, so if all you did was look and not touch on this one, 53 is appropriate. All right, if I had added in there if the patient had a polypectomy in, say, the transverse colon and you were unable to get beyond that, that's when the 52 modifier would be appropriate. But there was no instrumentation documented in this. So 53B is actually the correct answer. OK. All right, so the visit prior to screening colonoscopy from the Department of Labor. So the planner issuer may not impose cost sharing with respect to a required consultation prior to the screening procedure if the attending provider determines that the pre-procedure consultation would be medically appropriate for the individual because the pre-procedure consultation is an integral part of the colonoscopy. As with any invasive procedure, the consultation before the colonoscopy can be essential for the consumer to obtain the full benefit of the colonoscopy safely. The medical provider examines the patient to determine if the patient is healthy enough for the procedure and explains the process to the patient, including the required prep, all of which are necessary to protect the health of the patient. I think this kind of was a question that we got earlier, is do we have to examine the patient and take a history? Pretty well, they're saying, uh-huh, yep, you do. All right, so because the department's prior guidance may reasonably have been interpreted in good faith as not requiring coverage without cost sharing, the departments will apply this clarifying guidance for plan years beginning on or after the date, that is, 60 days after the publication. This was actually published in October of 2015. So this went into actually effect on 12-27 of 2015. And in July 1 of 2016, they established the code S0285. And this is approved by UHC, Cigna, Aetna, Anthem, Humana, and some of the other major payers. Some Blue Cross and Blue Shield plans also cover this code. Now, the only approved diagnosis codes right now are Z12.11, Z80.0, and actually Z83.71 now goes after that six digit, whether or not the family history is hyperplastic or unknown or adenomatous polyps. All right, so guys, yeah, it's covered. Again, this is the Affordable Care Act. So this, and I think the average reimbursement, and this is pretty well a question that we didn't answer before, but the average reimbursement for S0285 is based upon 99202, all right, so the new patient level two. We have seen that some of the commercial payers pay more than that. But you would have, since S0285 is not covered by Medicare, you will not see an approved amount in Medicare pre-scheduled, all right? So this is what you're going to have to do. You're going to have to look on the individual payer site to determine what their approved amounts are for this. Medicare does not cover the visit prior to screening or surveillance and considers this visit part of the pre-workup associated with the procedure. So the only time you can build a visit to Medicare is when you address something completely unrelated. And that problem will be built as the primary diagnosis. And that's kind of what we were talking before, making sure that your primary diagnosis is something that you actively are managing. And then the level of service would be based upon the decision-making for that encounter, all right? Now, the patient may be at high risk for the screening procedure due to other conditions. And this is CMS's policy, like COPD, et cetera, that affect the preoperative instructions given to the patient or how the procedure is performed. However, the consideration given to these risk factors is inclusive in the usual preoperative work associated with the procedure, all right? So reporting an EM service with a diagnosis code associated with one of the risk factors implies that the GI physician saw the patient in order to diagnose or manage that illness, all right? And that is usually not the case. The GI physician is seeing the patient in order to determine stability of the patient for the screening procedure. And CMS has stated that these visits are not billable. It's kind of a life is not fair rule on this. So in order for you to actually bill for this, they actually state that if those conditions are significant enough that cause you to not schedule the patient for that screening, then you can bill that visit, because those conditions make the patient too high risk for that procedure. But if you're actually managing the patient's condition, you're adjusting their medications prior to the procedure, and that's documented in your impression and plan, then yes, you are managing their condition. All right, so the visit prior to screening. So Medicare says no. The Medicare replacements say no on that. But as far as the commercial payers, we kind of were talking about that as well, all right? That they will cover these. All right, some ICD-10 hints. So we know that screening and diagnostic is contradictory. So you're looking at this is the guidelines in the ICD-10 book. Encounter for screening for malignant neoplasm, all right? And that is the heading. So it says excludes one, which means that you can't bill certain things together. So encounter for diagnostic exam, you are to code to sign or symptom. You cannot bill the sign or symptom with screening. So the provider must determine if the procedure will be done for screening or for diagnostic purposes prior to performing the procedure. It's one or the other. All right, so we've got some Z codes in here, Z08 and Z09. And this code, Z08, is encounter for follow-up exam after completed treatment for malignant neoplasm. And it says to use additional code to identify the personal history of malignant neoplasm. Z09 is this is after treatment for conditions other than malignant neoplasm. And so this is the personal history of codes, the personal history of polyps, all right? And then when you look at actually the Z85 category, it says to code first that Z08. And for Z86, for personal history of polyps, it says to code first any follow-up exam after treatment. So I know, doctors, that you're saying, OK, wait a minute. So what do I do with this? All right, so you're still going to put down the history codes in particular. But for the coders and billers, we are seeing payers that are following these guidelines. So if we're just billing Z86.010, whether you're doing this for a visit or whether you're doing this for the procedure, we're seeing denials back that says this is not a primary diagnosis. So what do we do? We use the Z09 code. The Z09, then, is primary to Z86.010. And then you would resubmit the corrective claim, and it should get paid. So it's Palmetto is one that follows these guidelines. All right, so for those of you that are under Palmetto for Medicare, also Cigna and Humana follow these guidelines as well. So any time you get a denial that says not a primary diagnosis, all right, and Neridian's another one, too, you would want to utilize the Z08 and Z09 codes in the first position. All right, so Z12.11 and Z80.0, this is the encounter for screening for malignant neoplasms. All right, so we know that family history, and this also would be family history of polyps as well, that it doesn't make a lot of sense. All right, if the payer's under the age of 45, all right, we have some payers that are automatically denied Z12.11 because you're putting them in the primary position. Remember that first diagnosis code would either cause payment or trigger a denial on this patient. So again, here we go again. We need to create a spreadsheet based upon payer preferences on anything related to screening issues regarding family history. All right, so it says usually screening begins at age 40 or 10 years younger than the person with colon cancer. All right, so you're recommending the age, and this is what we usually do for anybody under that age of 40. All right, when you're putting down family history, you recommend the age of the relative be documented in the common field, which is considered box 19. And you put something like mother diagnosed with colon cancer at age 48. So is this important that we have that on our endoscopy reports as well as in our any type of history? Absolutely. Asking the patient at what age was your mom diagnosed? At what age was your brother diagnosed? So it's first degree relatives that we're usually looking at for Medicare. As far as the second degree relative, it's usually two or more second degree relatives that Medicare does not follow those guidelines, but the commercial payers do. So it's so important that whoever is asking the patient questions, some of these patients you're not seeing up front. This is kind of an open access situation. They're asymptomatic. We're going to go ahead and schedule them up front. So again, making sure that whoever is doing this in your office is getting that information. All right, so it's up to your physician to be clear in their documentation, whether screening or diagnosis. If this is not clear, discuss this with them and have them make the appropriate legal corrections. Guys, hold the claims. If you know that there's something that has to be corrected, please do it. OK, so how do we do a legal correction? Actually, like I said, I was in a practice this past week. And this was actually a Medicaid plan that was reviewed by Optum, and I know a lot of you deal with Optum. All right, so what happened was this was a endorhider, and I won't name it up front, but I think we all know, especially docs, those of you listening, if you have to go in and correct your endoscopy report or even your visit note, you should not be able to unlock that note. There should be an option. This drives me nuts, because some of these electronic medical records allow you to do this. And you should have an option to either unlock it or do an addendum. Always do an addendum. So what happened with this practice is actually this was a screening colonoscopy. And what happened was that it was actually billed as 45378, because this was Medicaid, and they don't accept the G codes. All right, so this was 45378 with a 33 modifier. OK. The hospital billed it that way. Actually, the ASC billed it this way. But the provider billed it as 45380 with a 33, because of the fact that the pathology came through and showed biopsies were done. But the biopsy was not documented on the initial endoscopy report. And so what the practice did was they submitted this as 45380. They told the doctor to do an addendum and correct the record. But what happened was it wasn't corrected right away. So they submitted the claim as 45380. It came back, did not get paid, because what happened was the hospital got their note in first, and are their claim in first. And it was 45378, because the documentation didn't say a biopsy. All right, so what happened was then the practice had the physician do a late entry. Well, they did. The physician documented in there, went in and completely did the note, and said cold forceps biopsies were done in a transverse colon. But there was no addendum. It was completely just added in the note. And so what happened was Optum looked at the original note, then they looked at this note, and they said there wasn't a legal addendum done. So it was not a legal corrected note, and they would not allow it. All right, so guys, I'm telling you, don't just go in, unlock the note, and correct it. Do a legal correction on that note. Do an addendum. All right, I'm sorry. I kind of did a little bit more on this. But you know what? We see some things that go through. And we've always, Kristen and I have always said that. When we are looking at reports and records, and we do a review, and it's not signed, are there things that are not corrected legally, this is an issue. All right, so again, make sure that you do it. Make sure to assign the screening diagnosis in the proper ranking position. Check your MAC, local coverage determinations, and payer policies. Always check your explanation of benefits. EOBs are explanation of benefits for all denial reasons. And we all know sometimes it's not clear as to why claims are pended. And then also, and so important, make sure that you give the patients the information verifying the differences between screening, high-risk screening, and diagnostic procedures. All right, thanks. And we're gonna go on and talk about advanced endoscopy.

screening versus diagnostic colonoscopy

Affordable Care Act policy

Medicare screening colonoscopy loophole

differences between screening and diagnostic colonoscopy

screening modifiers

proper documentation and coding

insurance coverage and payer policies

coding and billing for colonoscopy