Gastroenterology Coding Alert

Retain your V-codes even if the screening turns diagnostic.

You should be following the rule that if your gastroenterologist performs colonoscopy screening on a patient, you must connect a “screening” diagnosis to the procedure, even if the physician discovers any abnormality in the process.

What your physician finds will decide your way forward in coding the colonoscopy. Make the best use of these rules to get the most out of your reimbursement.

Tip 1: Put G Codes to Good Use for Screenings

You can use either of the two G codes available when coding colonoscopy screenings for patients under Medicare: G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Don’t forget to attach appropriate diagnoses out of the following to bolster the G0105 reporting for high-risk patients:

• V10.05 —Personal history of malignant neoplasm; gastrointestinal tract; large intestine
• V10.06 —Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus
• V12.72 —Personal history of certain other diseases; diseases of digestive system; colonic polyps
• V16.0 —Family history of malignant neoplasm; gastrointestinal tract
• V18.51 — - Family history of certain other specific conditions; digestive disorders, Colonic polyps.

You can also code inflammatory bowel diseases, Crohn’s disease (555, Regional enteritis) or ulcerative colitis (556, Ulcerative eterocolitis) as primary diagnosis for justifying G0105.

In case of patients who are not in the high-risk category colorectal cancer (according to your gastroenterologist’s opinion), you will report G0121.You can shore it up with a primary diagnosis of V76.51 (Special screening for malignant neoplasms; colon).  “Many commercial carriers will allow practices to use the G codes and will appropriately identify them for payment.  Other carriers will insist on using the standard CPT® code 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 a colonoscopy without a biopsy or polyp removal.  Your staff may need to investigate the preference of the carriers in your region,” informs Dr. Michael Weinstein, MD, Vice President and member of the Board of Managers for Capital Digestive Care.

Scenario: Your physician performs a covered colonoscopy screening on a 45-year-old female with a personal history of rectal malignant neoplasms. You should opt for the high-risk CPT® code G0105 to code the procedure, due to the malignancy reported, and connect it to V10.06.  Alternatively, if the commercial prefers, use 45378 with the same ICD-9 diagnosis code.

Note: Pay attention to Medicare’s conditions for screening colonoscopies. You can report screening as frequently as once every 24 months for high-risk patients for colorectal cancer depending on the clinical circumstances. The most common interval is probably 5 years for most patients with a family history of colon cancer (V16.0) or a personal history of 1 or 2 small adenomatous polyps (V12.72).  In non-high-risk patients, you can report the procedure once every 10 years— but not within 48 months of a screening sigmoidoscopy.

Tip 2: Turn Code-Specific for Abnormal Findings

If your gastroenterologist finds a lesion during a screening exam and performs a biopsy or removal, you should shift your coding options. In this case, you should forget about G codes, and rely on a therapeutic colonoscopy code that specifically describes the resulting procedure.

Scenario: A 50-year-old asymptomatic patient receives his first colonoscopy screening. The gastroenterologist finds and removes by snare technique a colonic polyp during the exam. You should use 45385 (Colonoscopy, flexible, proximal to splenic flexure; with  removal of tumor[s], polyp[s] or other lesion[s]by snare technique) instead of G0121.

Tip 3: V Codes are Still Your Friends

Even if a screening colonoscopy later leads to a biopsy procedure or removal of a lesion, you should stick with the appropriate V code as your primary diagnosis.

“Whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination” (Medicare Learning Network Matters article SE0746, “Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscopy”), according to CMS instructions.

ICD-9 coding guidelines support the same principle. “A screening code may be a first-listed code if the reason for the visit is specifically the screening exam,” it states.

Caution: You should connect the biopsy/removal procedure to the “line 2” diagnosis in your report. This should be a polyp diagnosis and not a V-code.

In the example above, if a patient undergoes a screening that evolves into therapeutic colonoscopy with polyp removal by snare technique, you would report 45385. You should keep V76.51 as the primary diagnosis, and report a neoplasm diagnosis (for instance, 211.3, Colon polyp) as the secondary diagnosis.

Dealing With a Non-Necessitated Screening Request 

If an asymptomatic patient  insists on a colonoscopy that does not meet Medicare screening requirements, you could turn to an advance beneficiary notice (ABN) to bill the patient directly for the service.

An ABN tells the patient it’s likely that Medicare won’t cover the service, and therefore it will be the patient’s responsibility to pay. The patient can then determine whether he wants to have the procedure done.