Gastroenterology Coding Alert

You know your colonoscopy codes inside and out, but what if your gastroenterologist brings a patient in for a screening colonoscopy and finds a polyp -- do you know how to capture proper payment for screening-turned-diagnostic colonoscopies?

If you can overcome three common coding myths about these conversion procedures, you'll be sure to pick the correct procedure and diagnosis codes every time.

Fact: You'll use G codes to report screening colonoscopies, but when the procedure turns diagnostic your coding changes, too.

If your gastroenterologist performs a screening colonoscopy for a Medicare patient, choose between two G codes: G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for an average-risk patient receiving a screening colonoscopy, or G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for a high-risk patient, says Beth Rudd, CPC, CCP, billing supervisor for Tri-State Gastroenterology Associates in Crestview Hills, Ky.

Keep in mind: Private payers have their own rules, so you have to know how they want you to report a screening colonoscopy. For example, Rudd, who is in Kentucky says, "for our carriers, we use the 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]) for the screenings for all carriers other than Medicare."

When the gastroenterologist finds and treats a problem, you can no longer report the G code for the screening colonoscopy, says Cheryl H. Ray, CCS, CPMA, CGCS, coder/biller/auditor with Atlantic Gastroenterology in Greenville, N.C. Instead, you will use a Category I CPT code, based on the treatment or technique the gastroenterologist uses to biopsy and or remove the polyp. Any polypectomy or biopsy changes the CPT code for the colonoscopy.

Scenario: During a screening colonoscopy for an average-risk Medicare patient, the physician discovers several polyps. He removes the polyps during the same procedure using a snare technique. In this case, you should report the colonoscopy with polyp removal via snare technique (such as 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Watch out: Just because your gastroenterologist started out performing a screening colonoscopy and then ended up also treating a polyp, that doesn't mean you can report both a screening procedure code and a diagnostic procedure code. You should report only the diagnostic procedure code, without any modifiers.

Fact: If the gastroenterologist's documentation states that the patient presented for screening colonoscopy, you will use the screening V code (such as V76.51, Screening for colon malignancy) as the first ICD-9 code, Ray says. That may not be the only diagnosis code you need, however. If you're reporting G0105 be sure you also attach a secondary diagnosis code that will support the fact that the patient is high risk. For example, you might also use 555.0 (Regional enteritis; small intestine) and/or V16.0 (Family history of malignant neoplasm; gastrointestinal tract).