Summary: Providers need to be knowledgeable about the distinction between diagnostic and screening colonoscopy as well as specific payer codes and rules.
Colonoscopy is a common procedure performed by Gastroenterologists. CPT defines a colonoscopy examination as "the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis" as well. Coding for screening colonoscopies and assigning modifiers can be challenging for providers. To report services correctly, physicians and medical coding service providers need to understand the difference between diagnostic and screening colonoscopies, and surveillance colonoscopy, which is a subset of screening.
Diagnostic and Screening Colonoscopy · A Diagnostic colonoscopy is performed when an abnormal finding, sign, or symptom is found such as diarrhea, anemia, abdominal pain, or rectal bleeding · A Screening colonoscopy is performed on a person without symptoms in order to test for the presence of colorectal cancer or colorectal polyps. Even if a polyp or cancer is found during a screening exam, it does not change the screening intent. · A Surveillance colonoscopy is performed on an asymptomatic patient at an interval less than the standard 10 years from the last colonoscopy (or sooner, in certain high-risk patients), due to findings of cancer or polyps on the previous exam.
? Reporting a Screening Colonoscopy
The following ICD-10 codes are used to report a screening colonoscopy:
· Z12.11: Encounter for screening for malignant neoplasm of the colon · Z80.0: Family history of malignant neoplasm of digestive organs · Z86.010: Personal history of colonic polyps
Point to note: The order of the diagnosis pointers can affect how a payer processes the claim toward patient responsibility and this can be a big source of contention between patients, payors and providers. An article published in the Bulletin of the American College of Surgeons on May 1, 2016 instructs that if a polyp is discovered and removed during the same procedure, these ICD-10 codes should still be reported as the primary diagnosis codes, followed by the appropriate ICD-10 code for polyp: D12.0-D12.9 (benign neoplasm of the colon or rectum, based on location). However, MLN Matters SE0746 further instructs that if the physician finds a neoplasm during a screening exam, you should "indicate the secondary diagnosis using ICD-9 CM (now ICD-10) for abnormal finding polyp etc. Also, 2017 AHA ICD-10 CM/PCS Coding Clinic, First Quarter ICD-10 2017 page 9 states to assign the screening code as primary and to use your diagnosis pointer to assign the findings to correct code. Further clarification can be found on www.gastro.org under FAQ.
ICD-10 Codes associated with National Coverage Determination (NCD) for Colorectal Cancer Screening Tests
D12.6 Benign neoplasm of colon, unspecified K50 Crohn's disease K51 Ulcerative (chronic) proctitis K52.1 Toxic gastroenteritis and colitis K52.89 Other specified non-infective gastroenteritis and colitis K52.9 Non-infective gastroenteritis and colitis, unspecified Z12.11 Encounter for screening for malignant neoplasm of colon Z12.12 Encounter for screening for malignant neoplasm of rectum Z15.09 Genetic susceptibility to other malignant neoplasm Z80.0 Family history of malignant neoplasm of digestive organs Z83.71 Family history of colonic polyps Z85.038 Personal history of other malignant neoplasm of large intestine Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus Z86.010 Personal history of colonic polyps
Screening and Surveillance Colonoscopy Many providers are unsure about a screening and surveillance colonoscopy and how it should be coded for an asymptomatic patient. A www.gastro.org article explains:
· Follow-up colonoscopies are surveillance and not screening if a screening is a service performed in the absence of signs or symptoms, once the patient has a diagnosis of polyps--whether a sessile serrated adenoma (SSA), adenoma or hyperplastic. · An exam can be reported as a surveillance colonoscopy is the patient has a history of polyps, is now returning for a follow-up exam and is otherwise asymptomatic. Code Z86.010 (Personal history of colonic polyps) should be reported if the previous polyps were benign.
Different Codes for Medicare and Other Payers
The codes for reporting colonoscopies differ between Medicare and other payers. CPT codes are used to report colonoscopy to non-Medicare payers. Non-Medicare payers · If the patient is under a commercial plan, exchange plan or Medicaid, report colonoscopy using CPT codes45378–45398 45378 Colonoscopy 45379 Foreign body(s) removal 45380 Biopsy 45381 Submucosal injection 45382 Control of bleeding 45384 Hot biopsy 45385 Snare 45386 Dilation 45388 Ablation 45389 Stent placement 45391 Endoscopic ultrasound 45392 Endoscopic ultrasound with FNA 45390 Endoscopic mucosal resection (EMR) 45398 Band ligation
Point to note: Code 45378 is the base code for a colonoscopy without biopsy or other interventions. It includes brushings or washings, if performed. Report 45378 with ICD-10 code Z86.010 on the first line of the CMS 1500 form.
· If the procedure is performed through a stoma rather than the anus, report 44388–44408: 44388 Colonoscopy through stoma 44389 Biopsy 44390 Foreign body(s) removal 44391 Control of bleeding 44392 Hot biopsy 44401 Ablation 44394 Snare 44402 Stent placement 44403 Endoscopic mucosal resection (EMR) 44404 Submucosal injection 44405 Balloon dilation 44406 Endoscopic ultrasound 44407 Endoscopic ultrasound (EUS) with FNA 44408 Decompression
Medicare beneficiaries without high risk factors are eligible for a screening colonoscopy every ten years. Beneficiaries at higher risk for developing colorectal cancer are eligible for screening once every 24 months.
Medicare considers an individual who is at high risk for developing colorectal cancer as one who has one or more of the following:
· Close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp.
· Family history of familial adenomatous polyposis. · Family history of hereditary non-polyposis colorectal cancer. · Personal history of adenomatous polyps. · Personal history of colorectal cancer. · IBD, including Crohn’s disease, and ulcerative colitis.
For Medicare beneficiaries, screening colonoscopy is reported using the following HCPCS codes:
- G0105 (Colorectal cancer screening; colonoscopy on individual at high risk),for a Medicare beneficiary at high risk for colorectal cancer, and the appropriate diagnosis code that necessitates the more frequent screening.
- G0121 (Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk) and Z12.11 (Encounter for screening for malignant neoplasm of colon) or Z12.12 (Encounter for screening for malignant neoplasm of rectum) as appropriate.
Modifiers for Colonoscopy
· PT - CMS developed the PT modifier which indicates that a colonoscopy that was scheduled as a screening was converted to a diagnostic or therapeutic procedure. This is important so that Medicare knows to still waive the deductible but the patient is responsible for the co-insurance. · 33 - CPT developed modifier 33 modifier should be appended for preventive services when the primary purpose of the service is the delivery of an evidence-based service. For example, if a physician performing a screening colonoscopy finds and removes a polyp with a snare, use CPT code 45385 and append modifier 33 to the CPT code · 53 - Medicare guidelines state that if a patient is scheduled for a screening colonoscopy, but because of poor prep the scope cannot be advanced beyond the splenic fixture, the procedure should be coded as a colonoscopy with modifier 53 (discontinued procedure). The 53 modifier should be added even if the scope was advanced beyond the splenic fixture but the visualization was poor and the physician wants to repeat the procedure within the restricted time period. · 74 - Modifier 74 (discontinued outpatient procedure after anesthesia administration) should be appended when the colonoscopy is not documented as advanced at least into the transverse colon. The operative report must state why and when the procedure was discontinued. The extent and/or percentage to which the procedure was performed also should be documented. · 73 - Modifier 73 (discontinued outpatient procedure prior to anesthesia administration) should be appended when the procedure is cancelled prior to the insertion of the colonoscopy.
For calendar year (CY) 2017, CMS separated moderate sedation services from the majority of GI endoscopy procedures under Medicare Part B. As a result:
- This move has no impact on gastroenterologists performing their own moderate sedation for endoscopic procedures. Beginning January 2017, they now report two codes instead of one - the procedure code and the proposed moderate sedation code. - For gastroenterologists who use anesthesia professionals, the value of the majority of all GI endoscopy procedures has been reduced by 0.10 RVUs.
According to a study by the American Cancer Society, 90% of colorectal cancer (CRC) cases are detected in individuals over 50 years of age. Colonoscopy is the most effective and the most commonly adopted procedure for the diagnosis and screening of CRC in older adults. With complex coding and reimbursement challenges, providers would do well to partner with an experienced medical billing and coding company to ensure error-free claim submission for appropriate payment.
Natalie Tornese, CPC: Senior Solutions Manager Natalie is a Senior Solutions Manager responsible for Practice and Revenue Cycle Management at MOS. She brings 25 years of healthcare management experience to the company. Natalie has worked in varied leadership roles with practices and specialties. Her primary focus is revenue cycle management with an emphasis on Medical Billing, Coding and Insurance Verification Management. Natalie also holds a CPC certification by the American Academy of Professional coders (AAPC). She has written numerous articles on all aspects of Practice Management and presently manages a large team focused on Medical Billing, Medical Coding, Verification and Authorization services for MOS (www.outsourcestrategies.com)