Gastroenterology Coding Alert

And see what is still up for debate.

In Gastroenterology Coding Alert Volume 25, Number 1, we reported on the expanded coverage for colon cancer screenings as announced by the Centers for Medicare & Medicaid Services (CMS) in the CY 2023 Medicare Physician Fee Schedule (MPFS) final rule. The final rule left a few coding questions unanswered, but solid guidance is finally here.

Coding for these services can be complex, so let’s first review the CY 2023 MPFS final rule on colon cancer screenings, then discuss the updates the American Gastroenterological Association recently announced.

Remember Two Important Colonoscopy Coding Updates

Update 1: In order to comply with 2021 recommendations from the United States Preventative Services Task Force (USPSTF) and professional societies, CMS lowered the minimum age requirement for colorectal cancer (CRC) screenings from 50 to 45 years, effective January 1, 2023.

Update 2: CMS expanded the definition of colorectal screening tests to include comprehensive colorectal cancer screenings. This means that if a patient’s non-invasive stool-based test yields a positive result, Medicare will consider the follow-up colonoscopy as a preventative service. This eliminates the out-of-pocket cost for both tests. Being a cost-centric update, this could potentially enable more patients to undergo the screenings. “It makes the patient more at ease to follow through with more formal testing that helps better understand or quantify their condition,” 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.

Find Clarification on Payer Obligations and Cost Sharing

Payer obligations: Patients aren’t eligible for Medicare until age 65, but these updates will still positively affect a broad range of patients. Even most commercial insurance plans are required to cover and not impose cost sharing on colonoscopy following a positive non-invasive stool-based screening test or direct visualization. In these situations, just like in the Medicare fee-for-service program, colonoscopy is considered part of the CRC screening process. Additionally, most commercial payers must also cover polyp removal and other integral services without cost sharing.

Cost sharing: With the goal of completely eliminating cost sharing for services essential to the colonoscopy (including polyp removal) by 2030, Medicare is phasing cost sharing out incrementally. So, for dates of service in 2023 through 2026, coinsurance will be 15 percent. For 2027 through 2029, coinsurance will be 10 percent, then beginning in 2030, there will be no coinsurance. When the patient is not responsible for payment, providers can count on a more reliable revenue stream because payment comes from one source— the payer.

Understand Which Modifiers Apply

At the time CMS published the final rule, there was no formal industry guidance on how to submit a claim where a positive fecal test leads to a colonoscopy. Fortunately, the American Gastroenterological Association (AGA) has recently announced such guidance.

Commercial and Medicaid patients: When a colonoscopy follows a positive result for any of the non-invasive stool-based CRC screening tests listed below that occurred on or after January 1, 2023,the AGA suggests you submit modifier 33 (Preventive services) with the procedure code, such as 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) or 45380 (Colonoscopy, flexible; with biopsy, single or multiple).

Medicare patients: When a colonoscopy follows a positive result for any of the non-invasive stool-based CRC screening tests listed below that occurred on or after January 1, 2023, the AGA instructs you to submit HCPCS codes G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) along with Modifier KX (Requirements specified in the medical policy have been met).

Screening guaiac-based fecal occult blood test (gFOBT), CPT^® 82270 (Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection))

Screening immunoassay-based fecal occult blood test (iFOBT), HCPCS G0328 (Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous)

Cologuard™ – multi-target stool DNA (sDNA) test, CPT^® 81528 (Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result)

Note: Medicare will return claims with G0105 or G0121 submitted without the KX modifier as “unprocessable.” If this happens to you, simply add the modifier and resubmit the claim.

If the provider removed any polyps during the screening colonoscopy, report the appropriate CPT^® code such as 45380 or 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) and append modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure).

Know That ICD-10 Sequencing Has Not Been Finalized

As of now, ICD-10 has not formally instructed coders on how to sequence diagnosis codes in situations where a positive fecal test leads to a colonoscopy (which becomes therapeutic). As we reported back in January, “for the time being, add the ICD-10 code R19.5 [Other fecal abnormalities] as the third diagnosis below Z12.11 [Encounter for screening for malignant neoplasm of colon]. Also, code for the finding, such as K63.5 [Polyp of colon],” advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel advisor for ASGE in Pasadena, California. He also suggests watching how Medicare contractors and private payers process claims. “Patients should get no cost-sharing in this scenario,” Littenberg says.