When to use V16.0?

A Medicare patient has a screening colonoscopy 2 years after the previous c-scopy, because the provider considers the patient high risk with family history of colon cancer. However, upon investigation it is discovered that none of the patient's close relatives have had cancer, but a grandmother. According to Medicare definition family history means cancer in parents, siblings or children.

A) Since the patient has no personal history or any other reason for the procedure, this case should be coded as V76.51 instead of V16.0? is this correct?

B) What about commercial insurance claim? May we use V16.0, since the term "family history" is recorded in the chart?

re: When to use V16.0?

NO V16.0 describes family hx of cancer in imemdiate family. You also cannot use V76.51 because this is an every 10 year code.

re: When to use V16.0?

But is the definition for V16.0 by ICD-9_CM or Medicare only?

Also, we code high risk screenings (every 24 months) with V76.51 primary and V12.72 or V16.0 as secondary and have not had any denials..so, i do not think V76.51 is for average (every 10 year) screening only.

What are your thoughts on this?

re: When to use V16.0?

V76.51 is a Medicare screening for an asymptomatic patient every 10 years. BlueCross is the only carrier I bill V76.51 first on and then V12.72 or V16.0. If what you are doing is working then don't change it. BUt again V16.0 is for immediate family.

re: When to use V16.0?

V76.51 is a code in the ICD9 book, not specific to Medicare. To my knowledge, I have never seen instructions of any kind that tell you to use this code (or any other ICD9 code) every 10 years. I also use it each time the physician has dictated screening colonoscopy, which is typically every 2 years for Medicare patients, to both Medicare and any other insurance companies, and have never had a denial. I would also use V16.0 with any family member, and not tailor it to Medicare.