Gastroenterology Coding Alert

And check out these commonly misunderstood modifiers.

From differentiating between screenings and diagnostic procedures and picking the right modifier to including all the applicable procedures and including the appropriate documentation, coding colonoscopies can be tricky.

If you’re looking to clean up your colonoscopy coding, here are four common colonoscopy coding errors along with some tips about how to avoid them.

Common Error 1: Incorrectly Coding Colonoscopy Type

You want to distinguish whether the gastroenterologist performed a screening or a diagnostic/therapeutic colonoscopy. Codes and insurance coverage differ depending on the type of procedure, so it’s important to understand what took place.

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/).

Coding problems can arise when the provider goes into the colonoscopy with the intent to screen and ends up performing a polypectomy or removing a lesion.

How to code: When you’re coding for this scenario, you need to consider both the initial intent of the procedure as well as the changes that occurred. Because of the polyp removal, coding and billing will be different than if it was a simple screening with no potentially cancerous findings. Coding will likely look something like this:

1. Use the appropriate CPT^® code for a colonoscopy with polypectomy, which will depend on the method used for polyp removal, such as 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) or 45390 (Colonoscopy, flexible; with endoscopic mucosal resection).

2. Report the appropriate ICD-10 codes, which in this case will mean Z12.11 (Encounter for screening for malignant neoplasm of colon) to indicate that this was a screening for colon cancer, and K63.5 (Polyp of colon) to account for the finding as well as the location of the polyp.

3. Append the appropriate modifier to indicate the screening turned diagnostic.

As always, remember to check with the payer to ensure you’re following their guidelines. For example, Medicare will require you append modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) to account for the screening-turned-diagnostic situation. “Most commercial payers expect the 33 modifier (Preventive services) appended to indicate that scenario,” explains Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel advisor for ASGE in Pasadena, California. Each case may vary, so it’s important to consider the documentation and the patient’s specific circumstances.

Reminder: Even if the provider can make a guess as to whether the polyp is cancerous, don’t report whether the polyp was malignant or benign until the pathology report comes back. “Surgeons may imply what type of polyp it is in an operative report, but they usually defer to the pathology report before making a final recommendation about when the colonoscopy should be repeated,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, Calif. “The path report contains the definitive determination of a colon polyp’s behavior,” Brame continues.

Common Error 2: Misusing Modifiers

We discussed the need for a modifier to indicate a switch from a screening to a diagnostic procedure, but what about when the provider performs a biopsy and polyp removal during the same session? Or if the gastroenterologist has to stop the procedure before finishing?

In such cases, you can avoid payer problems by correctly appending the following modifiers to the appropriate colonoscopy procedure code:

• Modifier 51 (Multiple procedures): Append this modifier when there are two or more separate procedures performed during the same session by an individual provider. It signifies that the additional procedures are not just incidental to the primary procedure.
• Modifier 59 (Distinct procedural service): Append this one to indicate that the procedure was independent, unrelated, and distinct from other services provided during the same session.
• Modifier 53 (discontinued procedure): Use this when a procedure is discon­tinued due to extenuating circumstances like a patient’s health risk.

Again, keep in mind that each insurer may have specific requirements for modifier usage, so it’s essential to stay up to date on their guidelines to submit accurate and compliant claims.

Common Error 3: Not Reporting Biopsy and Polyp Removal Separately

You not only need a modifier to help the payer see that there was a biopsy and polyp removal in the same surgical session, but you also need to code each procedure with the accurate CPT^® code.

To represent these different procedures, you need to report two colonoscopy codes. Reporting two colonoscopy procedure codes does not mean that two colonoscopies were performed, which is where some coders get confused.

For example, to account for the biopsy, you will need to report a CPT^® code such as 45380 (Colonoscopy, flexible; with biopsy, single or multiple). You will also need to code the polyp removal procedure using the appropriate CPT^® code specific to the method of polyp removal. A common code for this is 45385.

Common Error 4: Incomplete Documentation

Incomplete or inaccurate documentation of the procedures performed, findings, or medical necessity often leads to denied claims, audits, and incorrect coding. Ensure that the documentation meets the requirements and supports the chosen codes for the colonoscopy procedures.

To avoid a denial for a claim for a screening-turned-diagnostic colonoscopy that includes a biopsy and polypectomy, submit clinical documentation that includes the following:

• Clear indication that the procedure began as a screening for a patient with no prior signs or symptoms that would necessitate a diagnostic colonoscopy;
• Details about the abnormal findings, such as polyps or lesions, that were discovered during the screening that led to therapeutic intervention;
• Specifics about the type of interventions, such as the polypectomy and biopsy;
• A comprehensive operative report that includes the gastro­enterologist’s notes that describe the entire procedure and any complications, if present; and
• Pathology report (if available), which helps support medical necessity.