# Opinion on Colonoscopy coding.



## chewri (Feb 24, 2014)

Could I get feed back on the following coding senerio's. Looking forward to your input.

Example #1

Indication: Colon screening
Post-endoscopy findings: Polyps in the cecum and sigmoid colon
Procedure: Colonoscopy with removal of cecal and sigmoid polyps by snare technique
Procedure code: 45385 (Colonoscopy with removal of polyp by snare)
Modifier PT (if Medicare patient) or Modifier 33 (if non-Medicare) should be added to indicate this was a preventive service and to trigger benefits
Diagnosis code: V76.51 (Special screening for malignant neoplasms, colon). Some Medicare payers instruct to only use the finding since the PT modifier indicates it was done for screening.

211.3 (Benign neoplasm, colon [based on pathology report])




Example #2

Indication: Personal history of colon polyps, Colon screening
Post-endoscopy findings: Normal colonoscopy
Procedure code: G0105 (High risk screening) or 45378-33 (Diagnostic colonoscopy with modifier 33 indicating this is a preventive service)
Diagnosis code: V12.72 (Personal history of colon polyps)


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## LMCODER (Mar 5, 2014)

The only thing I would do differently is on your example #2. You do not need to add the modifer 33 to a diagnostic scope unless it starts out being diagnostic and turns into a theraputic scope.


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## mitchellde (Mar 5, 2014)

for example number 1 you code the V code for screening first followed by the finding.  The indication for the study was screening and that must be the first listed code, the polyp was an incidental finding (something not expected or anticipated), and must be the secondary code, you link them both to the procedure with either the 33 or PT modifier depending on the payer.   
It is different if the patient is symptomatic and not screening, say rectal bleeding is the indication for the procedure and the finding is internal hemorrhoids which is causing the bleeding, since the provider was specifically looking for a cause, the hemorrhoids are not an incidental finding they are the diagnosis so you would code only the finding in that case.


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## Angeleke (Mar 5, 2014)

I agree with LMCODER. I code for a GI doctor and this scenario is common, But we don't use the 33 modifier.


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## Pam Brooks (Mar 5, 2014)

According to the Fourth quarter 2013 AHA coding clinic, the V12.72 is not the primary diagnosis for a surveillance Colonoscopy. A surveillance colonoscopy is still a screening....this is new.


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## trinalankford (Mar 5, 2014)

Stupid question....Is the 4th Quarter 2013 Coding Clinic on line anywhere? My doc is getting ready to retire so has not renewed a lot of his pubs. However, he also does a lot of colonoscopies. I'm thinking he will need to invest in this particular issue if it's not on line. Thank you.


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## mitchellde (Mar 5, 2014)

no the coding clinics are paid for subscription service and you are allowed to purchase individual issues.  just google AHA coding clinics and you will get to the correct order site.


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## chewri (Mar 12, 2014)

This was on the American Gastroenterology Association web site. This seems to be totally different then the way things were explained in Coding edge. All along I have been taught once a person has polyps or CA that no longer is the procedure considered screen/preventative and that you do not use mod 33 and that if no bx was taken and it was a screen you did not need to put a 33 on the 45378. Now I am totally confused. Any input would be greatly appreciated! The only one of these I would have coded the same would have been #5. 


Example #1

Indication: Colon screening

Post-endoscopy finding: Normal colonic mucosa

Procedure code: G0121 (Average risk screening) or 45378-33 (Diagnostic colonoscopy with modifier 33 indicating this is a preventive service).

Diagnosis code: V76.51 (Special screening for malignant neoplasms, colon)



Example #2

Indication: Personal history of colon polyps, Colon screening

Post-endoscopy findings: Normal colonoscopy

Procedure code: G0105 (High risk screening) or 45378-33 (Diagnostic colonoscopy with modifier 33 indicating this is a preventive service)

Diagnosis code: V12.72 (Personal history of colon polyps)



Example #3

Indication: Colon screening

Post-endoscopy findings: Polyps in the cecum and sigmoid colon

Procedure: Colonoscopy with removal of cecal and sigmoid polyps by snare technique

Procedure code: 45385 (Colonoscopy with removal of polyp by snare)

Modifier PT (if Medicare patient) or Modifier 33 (if non-Medicare) should be added to indicate this was a preventive service and to trigger benefits

Diagnosis code: V76.51 (Special screening for malignant neoplasms, colon). Some Medicare payors instruct to only use the finding since the PT modifier indicates it was done for screening.

211.3 (Benign neoplasm, colon [based on pathology report])



Example #4 

Indication: Personal history of colon polyps; Colon screening

Post-endoscopy findings: Large sessile polyp in the rectum, unable to resect, pending pathology

Procedure: Colonoscopy with biopsy of rectal polyp. Will await pathology and consider surgical referral.

Procedure code: 45380 (Colonoscopy with biopsy) 

Modifier PT (if Medicare) or Modifier 33 (non-Medicare) should be added to indicate this was a preventive service and to trigger preventive 

Diagnosis code: V12.72 (Personal history of colon polyps). Some Medicare payors [First Coast and Noridian] instruct to only use the finding since the PT modifier indicates it was done for screening.

211.4 (Benign neoplasm, rectum) or 235.2 (Neoplasm uncertain behavior, intestines and rectum [based on pathology report]).



Example #5

Indication: Change in bowel habits, here for colon screening

Post-endoscopy findings: Normal colon

Procedure: Colonoscopy

Procedure code: 45378 

Do not append modifier 33 or PT, as this service was performed for a diagnostic, not screening, indication. 


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## MAult142 (Mar 12, 2014)

I feel you, chewri.  It seems like every resource boasts an author with a different opinion on how to code colonoscopies.  Sometimes the same resource has multiple authors with multiple opinions.   I just passed my CGIC exam a couple months ago and I still manage to doubt my ability to code a colonoscopy sometimes. 

http://news.aapc.com/index.php/2013/03/colonoscopy-screening-or-surveillance/

The AAPC published the above article in March of 2013.  They advocate coding V76.51 primary to family history codes but state that it should never be used primary to personal history codes.  After reading it, I started coding V76.51 primary to family history codes on commercial plans.  Before that article, I was using the family history codes as primary.    I have worries about what will happen when the patient comes back for their surveillance colonoscopy in two to five years.  I still code the family history codes primary for Medicare, though.  Am I sure that this is right?  Some days I am.  Some days I'm not. 

I was studying for my CGIC exam last November.  A couple of the answers in the study guide suggested coding V76.51 primary to V12.72 and used the exact same section of the coding guidelines as the March 2013 article to justify their completely opposite position.   Two AAPC published resources from the same year, completely contradictory advice.  I still code personal hx codes as primary.  I still passed the exam. Maybe those are the questions I missed.  I don't know.

On Supercoder's forums, flip a coin.  You will get a different answer to the appropriate order and usage of the dx codes depending on who happens to be posting.  Same is true on these forums.  Every resource I find suggesting I do it one way, I can find another resource suggesting I do it the opposite way.  It's no man's land out there. 

I haven't read the AHA Coding Clinic for 4th quarter yet, but when I do, I suspect it will be just as full of grey areas as every other article I've read about the subject. 

I can answer a few of your questions though.  On examples 1 & 2, the reason why they're suggesting using modifier 33 on 45378 is that the code definition includes the word diagnostic: Colonoscopy, flexible, proximal to splenic flexure; diagnostic... so adding 33 indicates that this specific 45378 is preventative. I've used 45378 both with and without the modifier attached and I haven't noticed a difference in claims processing.  I use it more often than I don't.  Since UHC considers V12.72 and V10.05 to be diagnostic, I leave the modifier 33 off b/c I worry it will confuse things...more than they already are, that is. 

In examples 3 & 4, they're stating that because the original intent of the procedure was for screening and a therapeutic service was done, you attach either the PT for Medicare or the 33 for commercial to indicate the original intent of screening.  You're right the procedure is no longer screening/preventative once something more is done, but b/c that was the original intent, if you add the modifiers the patient is still eligible for their screening benefit.  Assuming, of course, that the insurance you're submitting to considered V12.72 to be preventative in the first place.  Most commercials don't. 

I hope I understood your questions and I hope I answered them without confusing you more.  If not, let me know and I will try again, or someone else may be able to do better.  I would give anything for a cut and dried, hard and fast, black and white, this is how you code a colonoscopy guide.  It doesn't exist.


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## chewri (Mar 13, 2014)

TY, You did not confuse me more just confirmed my confusion wasn't just a matter of me misunderstanding. I bill for a ASC and We work with 2 Dr.'s offices. I have to code AAPC way for one office and the AGA way for the other Dr. office. I have a hard time in right consciousness doing this. Feel it should be one way or another but I guess that's not  going to happen. Greatly appreciate your input and time. I too wish there was a clear cut answer!


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## Sephardic (Apr 18, 2014)

Pam, thank you for mentioning the new coding clinic article for guidance on V12.72. I have access to coding clinic through a website we subscribe too. I read the article from the AAPC about history of codes and screening. My heart dropped when I read it. I wasn't coding gastro at the time but I thought of all the screenings I coded incorrectly. I coded gastro for 4 years (then stopped a year ago) and am about to start again. Reading the coding clinic article made me feel so much better. It eliminated the confusion I felt after reading the AAPC article. I feel that the Coding Clinic is the authority on diagnosis coding and if they've made any statement about a code I follow their guidance. In hindsight after reading the AAPC article I did question the info. They implied you can't screen for something you have a history of. Which I get, but if you have a history of polyps V12.72 you should be able to screen for colon cancer V76.51. You're not saying you have a history of colon cancer, only polyps.


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## drakena74 (Jan 15, 2015)

I code for an ASC and I rarely use the -33 modifier. The only time I do is when we bill an insurance that our facility is out of network with & it's a screening, otherwise, I use mostly the G codes & -PT modifier.

#1 - 45385-PT; 211.3, V76.51
#2 - G0105; V12.72

You can code V12.72 as a Primary code in this instance because this person has a hx of colonic polyps.

 You really need to know each insurances policy & guidelines on colonoscopies because each want you to code/bill it a certain way. This is also why it gets so confusing.


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## daryleslie (Mar 17, 2015)

I too am confused. Have billed for a Colorectal surgeon for many years and I find conflicting information on everything.

I was taught that if it was a Screening Colonoscopy and a Polyp was found that you use the V76.51 as primary and your Polyp as a 2ndary diagnosis. But I read in the AGA as well as CMS guidelines and it states that if a polyp was removed that you do add both diagnosis on the claim form but in Item 24E (Diagnosis Pointer) you only mark your 2nd diagnosis to show the Polyp. Then you modify your appropriate procedure code with the correct modifier (PT or 33). That shows that the pt came in for the Screening, but a Polyp was found and removed. 

I can not seem to get a clear answer on that even though I've looked it up on those 2 websites. I have insurance companies calling me asking me to mark the Diagnosis Pointer area with both diagnosis. Anyone else having this problem?


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## daryleslie (Mar 17, 2015)

Also, if you change the order of your diagnosis just to get paid, isn't that a form of fraud? If you move your pointer to show that it was Screening and Polyp removal just so the pt doesn't get hit with a deductible, because that's what Insurance X is asking you to do.

You are supposed to bill how the guidelines are, not what gets paid.


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## dkrisak (Apr 2, 2015)

*Principal dx for surveillance colonoscopy*

This is now very confusing as an AAPC article written by Anna Barnes states that surveillance colonoscopies are not screenings and to code V12.72.  She states you cannot code V76.51 with V12.72.

Clinic Clinic, 4th Q 2013 states that surveillance colonoscopies are still considered screenings and to code V76.51 as first listed code and then code 
V12.72 as an additional dx and is considered a high risk screen G0105 I presume.

Clear as mud to me.  Any ideas on who to follow?  I don't see anything specific to this in the guidelines, so my guess would be to follow the coding clinic.


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