Gastroenterology Coding Alert

We’ve got one question for each coder — beginner, intermediate, and advanced.

Coding for colonoscopies may be a daily occurrence for most gastroenterology practices, but that doesn’t mean you aren’t occasionally stumped by a medical record. Whether you’re a brand-new coder or you’ve been in the game for decades, you could probably benefit from a quick refresher.

Check out the following three frequently-asked questions about colonoscopies — one for beginning coders, the second for those in the intermediate category, and the third for advanced coders.

FAQ 1: Beginning Coders

Question:  The provider performed a colonoscopy to remove a foreign body in the colon, but he was not able to reach the cecum or colon so he didn’t perform the removal. Which code(s) apply to this service?

Answer: The correct CPT^® code for this procedure is 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]). However, if the provider could not access the cecum or reach the small intestine, you will need to append modifier 53 (Discon­tinued procedure).

You’ll find an instruction for this at the introduction to CPT^®’s section on colonoscopy codes. The note reads, “When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (Colonoscopy…) or 44388 (Colonoscopy through stoma…) with modifier 53 and provide appropriate documentation.”

If, however, the scope wasn’t advanced beyond the splenic flexure, the correct code would have been 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), says Glenn Littenberg MD, a gastroenterologist in Pasadena, Calif. “If the incomplete colonoscopy was sufficient to reach beyond splenic flexure and remove the foreign body, the code would then have become 45379 (Colonoscopy, flexible; with removal of foreign body[s]), but in this case the modifier would be 52 (Reduced services),” he adds.

Payment issue: If you bill the way CPT^® advises, you won’t have to wonder how Medicare payers will calculate the fee. CMS clearly says in MLN Matters article MM9317, “Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.”

FAQ 2: Intermediate Coders

Question: During a screening colonoscopy for an average-risk Medicare patient, the physician discovers several polyps. He removes the polyps (which are later determined to be benign) during the same procedure using a snare technique. How should you report this screening-turned-diagnostic (also referred to as diagnostic-turned-therapeutic) procedure?

Answer: If a screening process results in a finding and the provider performs a therapeutic procedure in the same session, you should report the colonoscopy with polyp removal via snare technique (such as 45385, Colonoscopy, flexible, with removal of tumor[s], polyp[s], or other lesion[s], by snare technique) with modifier PT appended to 45385.

Modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure) indicates that a colorectal screening service was converted to a diagnostic or therapeutic service. The counterpart for a non-Medicare patient is modifier 33 (Preventive services), Littenberg says. “The ICD-10 code for colon cancer screening, Z12.11 (Encounter for screening for malignant neoplasm of colon), should ordinarily be the first code, reflecting the intention of the procedure being screening,” he advises.

“The importance to the patient is that the deductible for the procedure is waived for Medicare, while both deductible and copay are waived for the commercial payer patient,” Littenberg adds. This reflects the preventive service benefits, which under the Affordable Care Act, allow those patient responsibilities to be waived. “Without the modifier, there is a risk the patient gets charged for both deductible and copayment,” he says.

You’ll use the diagnosis code for the screening, as well as the ICD-10 code for the benign polyp, depending on the location, such as Z12.11 and D12.4 (Benign neoplasm of descending colon).

FAQ 3: Advanced Coders

Question: During a colonoscopy, the physician removes a polyp by snare and then also performs a biopsy of a second lesion at a different site. Should you report two codes with modifier 59 appended to the second code, orshould you only report one code — the most extensive service?

Answer: In this case, you can report both services as long as you append modifier 59 to the claim. Your coding should look like this:

• 45385 (Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for colonoscopy with polyp removal using the snare technique;
• 45380 (Colonoscopy, flexible; with biopsy, single or multiple) to describe colonoscopy with biopsy;
• Modifier 59 (Distinct procedural service) attached to 45380 to indicate that it is a separate and distinct procedure and denote the circumstance that makes it distinct, since ordinarily these two codes would not be performed the same day for the same lesion. “The second service would be applied to a differentlesion, different site,” Littenberg says. “Both could be polyps. If a biopsy was performed and then the same lesion was removed by snare, only the more extensive service (45385) would have been reported.”

Here’s why: The National Correct Coding Initiative (NCCI) bundles 45380 into 45385, but does allow you to use a modifier to differentiate between the two services. “In the NCCI tables, this is indicated by a “1” indicator next to the code pair,” Littenberg says. “When in doubt regarding which procedure to apply the 59 to, review the code pair in the NCCI. Some services, such as submucosal injection (45381) have no NCCI restriction when reported with services like biopsy or polypectomy, and thus no modifier is needed.”

Make sure your documentation clearly demonstrates the separate nature of the two procedures (separate site, separate technique, separate lesion) even though they were performed during the same session.