Gastroenterology Coding Alert

See if you’ve got what it takes to confidently command these questions.

Colonoscopies remain some of the most commonly miscoded procedures among gastroenterology practices. The confusion generally lies with nuances in the coding guidelines as well as gray areas surrounding screenings and diagnostic procedures.

This four-question quiz will offer you insight on some common colonoscopy quandaries to help you strengthen your skills.

Question 1: Will the new 2023 age guidelines for colonoscopy screenings affect which codes to use?

Answer: No, there are no new codes or guidelines associated with the Centers for Medicare & Medicaid Services (CMS) changing the screening age from 50 to 45. However, another change might eventually involve additional guidance on sequencing. Let’s explain.

As we reported in last month’s issue of Gastroenterology Coding Alert, in addition to lowering the minimum patient age to 45, CMS also expanded the definition of colorectal screening tests to include a complete colorectal cancer screening. This means Medicare will now consider the screening colonoscopy that follows a non-invasive stool-based test (with a positive result) to be a preventative service. “This is a positive change,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. “Patients have been struggling with the cost issue related to diagnostic services reported after the patient’s initial screening tool yielded a positive result,” she adds.

Because this is a new scenario, ICD-10 has not yet released guidance on how to sequence the diagnosis codes. For the time being, if a patient’s positive fecal test leads to a diagnostic colonoscopy with removal of a polyp, you’ll report Z12.11 (Encounter for screening for malignant neoplasm of colon), K63.5 (Polyp of colon), then R19.5 (Other fecal abnormalities) as the third diagnosis code, advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. In addition, add the modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) for Medicare or 33 (Preventive Services) for commercial claims, reflecting that a screening became diagnostic. As always, if you have any questions, contact the payer. And remember to be on the lookout for updated guidance.

Question 2: My provider wants to report an evaluation and management (E/M) service with every pre-colonoscopy screening visit, but I don’t think we should report the E/M. What’s the correct answer?

Answer: Although there are extenuating circumstances, it’s not likely each of your gastroenterologist’s patients’ situations justify reporting an E/M service for a pre-colonoscopy screening. Here’s why:

Typically, the prescreening visits don’t present new information that warrant the need for an E/M service. If you aren’t sure, look at the physician documentation and ask yourself, “what is the chief complaint for this visit?” If all that occurred is the typical information exchange that happens prior to the procedure, it’s clear that the documentation does not meet the medical necessity required to justify an E/M service.

Part B Medicare Administrative Contractor (MAC) Palmetto GBA recognizes that some gastroenterologists like to perform an E/M before colonoscopies but reminds coders that “the physician performing the colonoscopy may wish to see and evaluate the patient prior to the screening colonoscopy. In this case, the evaluation and management (E/M) visit is generally not separately billable.”

Even in patients deemed high risk, the reimbursement for the appropriate high-risk screening code (such as G0105, (Colorectal cancer screening; colonoscopy on individual at high risk)) already includes the preservice work associated with a screening colonoscopy in a high-risk patient, Palmetto advises.

Resource: To read Palmetto’s complete document on this topic, visit the Palmetto website www.palmettogba.com/.

Question 3: I’m coding anesthesia for a screening colonoscopy and esophagogastroduodenoscopy (EGD) with biopsy at a single encounter. Do I use the same anesthesia code for both or code them separately? What if I’m reporting a screening colonoscopy alone?

Answer: CPT^® Anesthesia section guidelines state you should report the anesthesia code that crosses to the most complex procedure when the patient has multiple surgical procedures during a single anesthetic administration. However, for upper and lower GI procedures during the same encounter, you’ll turn to single code 00813 (Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum).

Tip: Generally, reporting the anesthesia services separately will not only affect reimbursement but also raise a huge red flag in front of the payers.

To answer the second part of the question, you’ll want to code the anesthesia service for a screening colonoscopy alone using 00812 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy). But you should be careful when you do. Code 00812 has 4 base units in the ASA Relative Value Guide^® but a different number of base units (3) in the Medicare 2022 base units file (available at www.cms.gov/Center/Provider-Type/ Anesthesiologists-Center). So, you need to know which base units your payer uses when you calculate expected payment for 00812.

Remember that payers may have their own guidelines for reporting these services, so be sure to check payer policy.

Question 4: During a screening colonoscopy, the surgeon documented finding hemorrhoids, but did not document anything about treating the condition. Should I code this as diagnostic because of the abnormal finding?

Answer: No, you should not code this as a diagnostic colonoscopy in this case. This is of course assuming you have documentation that the ordering physician requested a medically appropriate screening colonoscopy.

Procedure refresh: Let’s first start by differentiating a screening from a diagnostic test. According to the American Gastroenterological Association, “A screening test is a test provided to a patient in the absence of signs or symptoms … for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.” A diagnostic colonoscopy, however, is performed “as a result of an abnormal finding, sign or symptom” (source: https://gastro.org/practice-resources/ reimbursement/coding-faq-screening-colonoscopy/).

The hemorrhoids are considered an incidental finding, not something that creates a cancer scare. During a screening procedure, the surgeon should document these findings for the sake of the medical record and future care. But these findings don’t change the fundamental nature of the procedure, so there’s no need to change the procedure code. In addition to hemorrhoids, incidental colonoscopy findings might include diverticulosis or anal fissures. You should report these as a secondary diagnoses following the ordering diagnosis of Z12.11 (Encounter for screening for malignant neoplasm of colon) as the primary code.