CMS Stops Colonoscopy Confusion Cold

‘Screening turned diagnostic’ calls for screening ICD-9, diagnostic CPT
A recent CMS Transmittal has called an end to conflicting guidelines on how to diagnose a screening colonoscopy during which the physician finds a polyp or other abnormality. Coders should find relief in the CMS announcement: The issue of how to report a "screening turned diagnostic" has been the subject of confusion for some time (see Ambulatory Coding and Payment Report, Vol. 13, No. 1, pages 1-3, for complete information).

Medicare Requires G Codes for Screening Exam

For Medicare patients, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk: APC 0158) for an average-risk patient receiving a screening colonoscopy, or G0105 (Colorectal cancer screening; colonoscopy on individual at high risk: APC 0158) for a high-risk patient.
You will assign a V code as the primary diagnosis with any screening colonoscopy. For low-risk patients, you should cite V76.51 (Special screening for malignant neoplasms; colon).
When reporting G0105, however, you must supply evidence to support the patient’s high-risk status. Some diagnoses that Medicare considers high-risk factors for colorectal cancer, and that therefore justify a high-risk screening, include:

• V10.05 -- Personal history of malignant neoplasm; gastrointestinal tract; large intestine
• V12.72 -- Personal history of certain other diseases; diseases of digestive system; colonic polyps
• V16.0 -- Family history of malignant neoplasm; gastrointestinal tract
• V18.5 -- Family history of certain other specific conditions; digestive disorders
• 555.0 -- Regional enteritis; small intestine.

Note: This is not an exhaustive list of diagnoses that payers may accept for G0105. Check with your individual payer for its guidelines.
A Polyp Transforms Procedure Coding

When a screening exam uncovers a polyp, you will turn away from the G codes to report the procedure and instead select an appropriate category I CPT code, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.
Example: The physician begins a screening colonoscopy for an average-risk Medicare patient. She then finds a polyp, which she biopsies.
In this scenario, you should choose 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple: APC 0143), without any modifiers, rather than G0121.
In other words: If during the screening colonoscopy, the physician detects a lesion or growth that results in a biopsy or removal of the growth, you should bill -- and be paid for -- the appropriate diagnostic procedure (in this case, 45380) rather than G0121.

Polyps Won’t Affect Dx Coding
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- Published on 2008-02-12