Gastroenterology Coding Alert

Plus: learn the subtle difference between “diagnostic” and “therapeutic.”

Colonoscopies are coded regularly by gastroenterology coders, but often incorrectly. There is a lot to consider when picking the correct codes, and those nuances can easily trip coders up.

In her August webinar titled “The Ins and Outs of Colonoscopies,” Kristie Harris, RHIT, CPC, coding educator for a hospital system in Oklahoma, broke down the basics of colonoscopy coding. If you could use clarification on low-risk versus high-risk screenings, screenings turned diagnostic, and tips on how to avoid common errors, this one’s for you.

Code What the Doctor Ordered

Anytime you’re dealing with a colonoscopy claim, the basic thing to remember is to code based on how the provider ordered the procedure. This is to help prevent the patient from having to pay out-of-pocket unexpectedly. The history and physical section associated with the surgery should tell you clearly whether the patient was in for a low- or high-risk screening or diagnostic procedure.

Low-risk screening: An patient is considered low risk if they:

• Are asymptomatic
• Have not have a colonoscopy in the last 10 years
• Have no personal/family history of colorectal cancer
• Have no personal history of polyps

Example: Let’s say the provider documented that this is the patient’s first colonoscopy, and they have no symptoms and no personal or family history of colorectal cancer. The documentation indicates this patient should have a screening colonoscopy and that they are a low-risk patient.

High-risk screening: An patient is considered high risk if they:

• Are asymptomatic
• Have a personal/family history of colorectal cancer
• Have a personal/family history of polyps
• Are undergoing surveillance for ulcerative colitis or Crohn’s colitis

Example: Now consider a patient who has had colorectal cancer in the past and the provider ordered a colonoscopy for surveillance after previous cancer treatment. This would be considered a high-risk screening colonoscopy. “The word ‘surveillance’ indicates there was a prior diagnosis and the subsequent exam relates back to the prior finding, such as prior cancer, prior polyp, prior ulcerative colitis. However, coding for the procedure employs the term ‘screening’ even though medically speaking, these circumstances (follow-up of prior disease), are considered surveillance,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT® Editorial Panel advisor for ASGE in Pasadena, California.

Diagnostic: The provider will order a diagnostic colonoscopy if the patient exhibits symptoms that commonly indicate colorectal cancer.

Example: If the provider documents that a patient is experiencing abdominal pain and bleeding in their stool, the documentation should indicate the need for a diagnostic colonoscopy to determine the cause of the symptoms.

Pay Attention to Payer Preferences

Because of the differences between what Medicare and commercial payers will accept, figuring out how to properly code screenings versus diagnostic procedures is often where coders start to second-guess themselves.

Medicare recognizes the following screening codes:

• G0105 (Colorectal cancer screening; colonoscopy on individual at high risk)
• G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)

Medicare also recognizes the 45378-45398 (Colonoscopy, flexible…) diagnostic code set.

However, not all commercial payers accept Medicare screening codes. “If the commercial payer does not recognize the Medicare codes for the screening, then diagnostic colonoscopy code 45378 from the diagnostic code set will need to be reported with modifier 33 [Preventive services].” said Harris. The modifier tells the payer that the provider performed a colonoscopy but that it was a preventive screening.

“The most common situation where Medicare and commercial payers may differ is when the patient had a prior colon polyp and the surveillance exam was done, but we report ICD-10 code Z86.010 [Personal history of colonic polyps],” explains Littenberg. The issue here is that Medicare will accept G0105 if nothing is found and therefore waive the copay and deductible. Many commercial payers will want 45378, but the diagnosis code Z86.010 means there will still be a copay and deductible. “Patients very frequently misunderstand this situation and figure the follow-up is a ‘screening,’” Littenberg continues. There isn’t an easy way around this, but it is sometimes helpful to have a payer representative discuss this situation with the patient.

Solidify Your Understanding of Screenings Turned Diagnostic

This is the next place things can start to feel particularly tricky. Often the provider will order a screening colonoscopy and during the procedure will find suspicious tissue and remove it. The procedure started as a screening, but the provider actually carried out a diagnostic procedure.

To code this, you’ll append modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) to account for the switch. For example, let’s say a high-risk screening turned up a polyp which was removed. The provider performed a diagnostic procedure, so you’d use a code such as 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) and append modifier PT. “Since this started as a screening, appending modifier PT will alleviate any out-of-pocket for the patient and keep the service covered as a preventive. Medicare does in fact accept this modifier and, in my experience, so do most commercial payers,” said Harris.

Medicare requires the PT modifier, but some payers do not accept it. Those payers may instead require modifier 33 (which Medicare does not recognize) to indicate the preventive service. Be sure to check with the payer before submitting the claim.

Documentation alert: Some providers use the terms “diagnostic” and “therapeutic” interchangeably. The code set is the same, but there is a slight difference between the two terms. A provider plans a diagnostic procedure because of a symptom or lab or imaging finding that requires the procedure to diagnose something (or maybe find nothing). Therapeutic colonoscopies may start off as screenings, but then something is found, treated, and the actual procedure is then considered to be therapeutic. That being said, while technically the above situation is considered a screening colonoscopy turned therapeutic, “payers tend to use the term ‘diagnostic’ in this scenario,” explained Harris.

Coding alert: Not all diagnostic findings lead to a therapeutic procedure, and coders sometimes misunderstand that. “If the procedure started as a screening, but there were diagnostic findings that did not lead to a switch from screening to therapeutic, modifier PT is not applicable and therefore the screening code is the best choice,” Harris said. A common example would a provider finding diverticulosis, which is something a coder would report as a finding but wasn’t the reason for the procedure and didn’t result in anything additional.

Avoid This Common Error

Be careful to not inappropriately report CPT® 45382 (Colonoscopy, flexible; with control of bleeding, any method) to address bleeding. Remember that control of bleeding is included in most endoscopic procedures, but 45382 is specific for controlling bleeding caused outside the colonoscopy procedure itself. Think of it this way: “If the provider caused the bleed, they should fix the bleed,” said Harris. For example, if the provider takes a biopsy and it causes bleeding, the original procedure code includes addressing that bleeding and control of bleeding is not separately billable.