Incorrect Coding of Colonoscopies (Diagnostic versus Screening)

Recent errors assessed by the Comprehensive Error Rate Testing (CERT) contractor include medical necessity errors for diagnostic colonoscopy services. Based on medical record review, the documentation did not meet the criteria to support payment under Medicare regulations. In these cases, the services should have been billed with the appropriate screening colonoscopy code.

The following is an example of the CERT contractor comment for one of these cases: For date of service 06/19/2009, billed CPT 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). Submitted documentation includes the initial evaluation, a history and physical done prior to the procedure, and the operative note. The diagnosis provided is diverticulosis, which is an ICD-9 code that supports Medical Necessity per the Local Coverage Determination (LCD) in effect for this date of service; however, the documentation received does not support the diagnosis. The reason stated by the rendering physician is the patient has a family history of colon polyps. Based on the documentation, the billed service does not meet the criteria for the code submitted.

You can access the WPS Medicare LCD for Colonoscopy and Sigmoidoscopy - Diagnostic (L30304) on the WPS Medicare website by selecting the Policy tab on the top navigation bar, then Active/Final Policies.

Page Last Updated: Monday, 23-Apr-2012 15:12:42 CDT