Gastroenterology Coding Alert

Due to recent publicity campaigns touting the benefits of colorectal cancer screenings and a new screening benefit for average-risk patients, more Medicare beneficiaries have been seeking screening colonoscopies from gastroenterologists. Because Medicare carriers have been slow to release updated guidelines for these benefits, the increase in demand for screenings has also brought an increase in questions, such as how to bill for an E/M service prior to the screening or the proper way to report a discontinued procedure.
 
Medicare's national policy for screening colonoscopies includes the following:
 

Screening colonoscopies (G0105) for beneficiaries at high risk for developing colorectal cancer one every 24 months. Although the criteria for those who are considered to be at high risk varies from carrier to carrier, most carriers will cover those individuals who have a personal history of colon cancer (V10.05) or cancer of the rectum (V10.06). They also cover individuals with Crohn's disease (555.0-555.9) or ulcerative colitis (556.0-556.9). Some carriers may also cover individuals with a personal history of colonic polyps (V12.72), family history of colorectal cancer (V16.0) or a family history of digestive disorders (such as colonic polyps) (V18.5).
 

Screening colonoscopies (G0121) for beneficiaries not meeting the criteria of high-risk one every 10 years. Note: Prior to July 1, 2001, this code was used to report non-covered screening colonoscopies on Medicare beneficiaries who did not meet the criteria of high-risk. The national policy does not list a diagnosis code that should be used when reporting the average-risk screening but most carriers accept V76.51 (special screening for malignant neoplasms; colon).

Probably the most common question that is asked with regard to both types of screenings is whether Medicare will reimburse for an E/M service performed in conjunction with the screening. The general consensus among coding experts is that Medicare will not reimburse for an E/M service that deals only with the screening about to be performed. Some gastroenterology medical societies have been lobbying CMS for a change in this policy.
 
"Our gastroenterologists always perform a history and physical before each screening," says Carol Pohlig, CPC, BSN, RN, a reimbursement analyst for the Hospital of the University of Pennsylvania Department of Medicine. "But that's just part of the procedure, part of the global package, even if it's only a one-day package."
 
Some practices report that they do not do a full-blown E/M in an "open-access" situation where the patient's primary care physician arranges for the screening. Instead, a nurse may speak to the patient over the phone prior to the colonoscopy or the gastroenterologist may review the primary care physician's records in advance.
 
In cases where the patient needs to see the gastroenterologist prior to the screening because no other physician has seen him or her, many practices bill the patient for the E/M service. "We have a waiver signed if the patient is seeing the gastroenterologist strictly about having a screening," says Roberta Clausen, CPC, CPC-H, a member of the American Academy of Professional Coders national advisory board and financial manager of Charleston Gastroenterology Specialists in S.C.
 
Clausen bills Medicare for the E/M service but attaches modifier -GA (waiver of liability statement on file). The modifier indicates to the carrier that a waiver has been signed, and the carrier sends a notice to the patient that he or she is required to pay for the E/M service. "If you bill an E/M service with a V code and modifier -GA to Medicare in South Carolina, it tells the patient that he or she has to pay the physician," Clausen explains. "It just makes it easier for us to collect from the patient."

When the patient sees the gastroenterologist for a reason other than the screening, it may be possible to get reimbursement for the E/M session. "Sometimes there are issues that have to be addressed other than the screening," Pohlig says. "The patient might also have reflux and the gastroenterologist wants to make sure that is under control."
 
In this situation, Pohlig would bill for an E/M service but the diagnosis would be for reflux (530.81), not the screening diagnosis. In addition, she would attach modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code if the visit is on the same day as the screening. "Medicare will usually pay for these visits," she says.
 
Some gastroenterologists would like to bill an E/M service for the session after the procedure where the results are reviewed with the patient. However, this practice raises a red flag with most coding experts. "My question is what is the medical necessity for a consultation or any other type of E/M service after the colonoscopy," Clausen says. "The gastroenterologist is required to give the results after the procedure; that's not something that can be billed separately."
 
There is one situation that Pohlig can think of where it might be justified to bill for a post-procedure E/M session when the gastroenterologist goes over treatment and management options with the patient. "Simply reviewing the results is part of the normal routine, but if you are going over a new treatment or management option like putting someone on a new diet that could be considered separate and identifiable," she says.

Incomplete screening colonoscopies are another source of coding confusion. Although Medicare has a well-established policy of attaching modifier -53 (discontinued procedure) to the code for a diagnostic colonoscopy, it has issued no such guidelines when it comes to screenings. In addition, there is an entry for incomplete diagnostic colonoscopy (45378-53) in the Medicare physician fee schedule database that indicates the reimbursement for the procedure, but there is no corresponding entry for any of the screening codes.
 
Without a formal guideline, most coding experts agree that modifier -53 should be attached to the G codes for a screening. "We have had some discontinued screenings, usually due to poor patient prep," says Albert Shaw, practice manager at Asher, Kornbluth MDPC, a three-physician gastroenterology practice in New York City. "We add modifier -53 to the G code to indicate an incomplete colonoscopy, just as we would do for a diagnostic screening. The reimbursement is the same as a flexible sigmoidoscopy, but using the modifier justifies the patient coming back in a week or two for a repeat screening."
 
Shaw cautions, however, that the operative report should be reviewed before billing for an incomplete screening colonoscopy. "You need to double-check that it really was incomplete, that it did not advance past the splenic flexure," he explains. "The gastroenterologist may write that it was incomplete because he or she was not able to advance the endoscope all the way to the cecum. But if it's past the splenic flexure, Medicare considers it to be complete."
 
To further indicate that this was an incomplete screening, V64.1 (surgical or other procedure not carried out because of contraindication) should be submitted with the claim, Pohlig recommends.

Some carriers have overlapping diagnosis codes for diagnostic and high-risk screening colonoscopies, which may cause gastroenterology practices to question whether a follow-up colonoscopy should be reported as a diagnostic or screening procedure. The situation usually arises when a patient has a personal history of colon cancer or a digestive condition such as Crohn's or ulcerative colitis.
 
For some practices, this isn't a concern because their carriers don't have overlapping diagnosis codes. "In South Carolina, we don't have that issue. If you aren't having any problems, any signs or symptoms, then it's a screening. If you had cancer in the past, but no problems now, then it's a screening," Clausen says. "If the screening falls within the two-year time frame of a high-risk screening, you can bill it as G0105, but if the patient is coming back less than 24 months after their last screening, it won't be covered."
 
With Pennsylvania carrier HGSA, however, personal history of colorectal cancer, Crohn's disease and ulcerative colitis are listed as covered indications for the diagnostic and screening colonoscopies. Determining which code to bill in this situation is often a matter of reading the local medical review policy (LMRP), Pohlig says.
 
For example, the HGSA LMRP specifically states that a diagnostic colonoscopy can be billed for a patient with chronic irritable bowel disease (IBD) if a more precise diagnosis is needed or to determine the extent of the disease. If the IBD is chronic and stable, then a high-risk screening colonoscopy (G0105) should be billed instead.
 
In addition, the HGSA policy allows a diagnostic colonoscopy every three to five years following a resection for colorectal cancer and every one to two years for patients who have had pancolitis for the past seven years or left-sided colitis for the past 15.

If the LMRP is not clear on what should be reported, Shaw tends to bill for a diagnostic colonoscopy whenever possible because these are usually situations where a significant E/M session will take place prior to the procedure. That E/M session is more likely to be reimbursed when billed in conjunction with a diagnostic colonoscopy.
 
"If the gastroenterologist is seeing the patient for more than just the pre-procedure E/M, perhaps to check on medications or to order other diagnostic tests, then that is a separately identifiable service," he explains. "But even if it is appropriate and justifiable, our carrier won't reimburse for it if it is billed with a screening. So whenever possible, we try to bill a diagnostic colonoscopy."
 
While many non-Medicare patients have expressed interest in having a screening, whether a commercial payer will reimburse for the procedure or which codes should be used to report it will vary from payer to payer. "Many of our HMOs have screening benefits," Clausen says. "Some use the HCPCS G codes, while others accept the diagnostic procedure codes with a screening diagnosis."