Gastroenterology Coding Alert

V codes fit primary diagnosis, but only for screening high risk patients.

Confused about when to use G codes or how to sequence your polyp codes? Medicarespecific G codes for colorectal cancer screening, secondary diagnosis coding, and modifiers PT or 33 may just provide you with the needed help. The key to these situations is two-fold: knowing the patient's history and highlighting the physician's findings.

Background: Many health providers have a tough time resolving Medicare coverage for colonoscopy, particularly the issue of distinguishing between screening and therapeutic colonoscopies. Because of a legislation passed in 2010 which waived Medicare deductibles and copay percentage, gastroenterologists and patients now expect Medicare to cover all colonoscopy-related expenses. In reality, however, the waiver only applies to a colonoscopy performed for average risk colorectal cancer screening, a service rated "A" by the US Preventive Services Task Force (USPSTF). This means a patient will have to shell out more money to pay for colonoscopy performed for high-risk indication (surveillance) or for any resulting therapeutic colonoscopies. This ongoing confusion should make you extra cautious when reporting colonoscopy procedures.

Here are two tips on what you should or should not do when faced with different colonoscopy situations.

Tip 1: Reserve G Code For Medicare Eligible Patients

When screening a patient under Medicare, you should rely on two codes: G0105 (Colorectal cancer screening; colonoscopy on individual at high risk), which defines patients as "high risk," and G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk), which describes patients as "not meeting criteria for high risk" -- or typically the average risk patient, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT® Advisory Panel.

Quick fact: Medicare will pay for screening colonoscopy as often as once every 24 months for those patients defined as "high risk" for colorectal cancer depending on the clinical circumstances, or once every ten years -- but not within 48 months of a screening sigmoidoscopy -- for those patients who do not qualify as "high risk."

For G0105, you would choose only from the following select diagnoses from the personal and family history ICD-9 category to support a high risk classification:

• V10.05 -- Personal history of malignant neoplasm of large intestine;
• V10.06 -- Personal history of malignant neoplasm of rectum rectosigmoid junction and anus;
• V12.72 -- Personal history of colonic polyps;
• V16.0 -- Family history of malignant neoplasm of gastrointestinal tract;
• V18.5 -- Family history of digestive disorders.

Medicare also approves inflammatory bowel disorders (IBD), such as Crohn's disease (555, Regional enteritis) and ulcerative colitis (556), for G0105. In Crohn's disease, parts of the digestive system get swollen, while in ulcerative colitis the lining of rectum and colon develop ulcers.

Example 1: A gastroenterologist sees a 65-year-old Medicare patient for colonoscopy screening. The patient has a personal history of malignant neoplasm of the large intestine. In this case, report the high risk code G0105, and link it to V10.05, the primary diagnosis.

Example 2: If the patient does not meet any of the high risk criteria for colorectal cancer, say an asymptomatic, 70-year-old male patient receiving his first Medicarecovered colonoscopy screening, you would code G0121 for the procedure, and report V76.51 (Special screening for malignant neoplasms colon) as the primary diagnosis.

What about billing private payers for screening? Most non-Medicare payers accept 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 screening colonoscopy and the associated  diagnosis code of V76.51 to designate average risk screening. (See Tip 3 for info on modifier 33 use.)

Tip 2: Link Polyp Code As Secondary Diagnosis For Abnormal Findings

Suppose the gastroenterologist discovers a lesion during the exam. Because this colonoscopy is no longer a screening exam, you should strike the G code from your coding possibilities.

Instead, rely on a diagnostic colonoscopy code that appropriately identifies the physician's ensuing treatment (i.e., biopsy or removal). Remember, you should use Medicare-specific G codes for screenings only. The Medicare Benefit Policy Manual (280.2.2.C) states, "If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than G0105."

If the physician biopsies a polyp during the exam, you would report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).

If he removes the polyp by snare technique during the exam, you would code 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). If the physician used hot biopsy forceps to remove the polyp, you would report 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery).

Caveat: You should retain the appropriate V code as your primary diagnosis even if the physician biopsies or removes a lesion during what began as a screening colonoscopy. According to the MLN Matters article Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscsopy, "CMS advises that, 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." (You can find this article at http://www.cms.gov/MLNMattersArticles/downloads/se0746.pdf.)

However, you should link an appropriate polyp diagnosis to the therapeutic colonoscopy (CPT® Category I) code. So, if our first example of a 65-year-old Medicare patient turns into a colonoscopy with biopsy from the original screening colonoscopy, you would report 45380, and list V10.05 as  primary diagnosis, and an ICD-9 code describing the polyp as secondary diagnosis (e.g., 211.3, Benign neoplasm of colon).

Tip 3: Recognize When To Draw On Modifiers 33, PT

Say a 67-year-old Medicare patient at average risk for colorectal cancer reports to the surgeon for a scheduled screening colonoscopy. During a complete screeningcolonoscopy to the cecum, the physician identifies and removes a pair of polyps from the ascending colon using hot biopsy forceps. The pathology indicates that these polyps were benign.

In this case, you would report 45384 with 211.3 (Benign neoplasm of other parts of digestive system; Colon). Youwould not bill G0105 because the Medicare G codes are for screenings only.

Modifier PT: For Medicare contactors, providers should append modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure) "to the diagnostic procedure code that is reported instead of the screening [test] when the screening test becomes a diagnostic service," according to the Medicare Physician Fee Schedule Final Rule published in the Nov. 29, 2010 Federal Register. In our example, you would bill with 45384-PT.

Modifier 33: On the other hand, modifier 33 identifies screening/preventive services. Usually, the lack of signs or symptoms would tell you that the service is a screening colonoscopy. If the physician found no polyps, you should append modifier 33 to the screening colonoscopy code (e.g., G0105-33).

This modifier is applicable for the identification of preventive services without cost-sharing in these categories:

1. Services rated "A" or "B" by the US Preventive Services Task Force (USPSTF) (see Table 1) as posted annually on the Agency for Healthcare Research and Quality's Web site (http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm);

2. Preventive care and screenings for children as recommended by Bright Futures (American Academy of Pediatrics) and Newborn Testing (American College of Medical Genetics) as supported by the Health Resources and Services Administration; and

3. Preventive care and screenings provided for women (not included in the Task Force recommendations) in the comprehensive guidelines supported by the Health Resources and Services Administration.