Gastroenterology Coding Alert

Know the difference between screening, diagnostics and surveillance.

Do you feel uneasy when handling coding for screening colonoscopies? Well, you are not alone. Coding for screening colonoscopies can be confusing at times, because the code choices depend on a meticulous analysis of the coding rules. Grasp the nuances of a screening colonoscopy, and how to report the follow-up cases.

First, Get the Basics Right

Screening colonoscopy: “A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps,” according to the American Gastroenterological Society (AGA). Even if the provider identifies a polyp during the process, the basic intent of the procedure would still be counted as screening.

Diagnostic colonoscopy: The provider performs this procedure when a patient presents with a history and/or symptoms that require investigation, says Michael Weinstein, MD, former representative of the AMA’s CPT^® Advisory Panel. This might include issues like chronic diarrhea, significant hematochezia, or a questionable abnormality noted on an imaging study, he says. Assuming an office note or pre-procedure note is created detailing the patient’s complaint history then the subsequent procedure will be a diagnostic colonoscopy. This is true even if the patient has never had a prior routine screening colonoscopy and mentions that the insurance company representative told them the procedure would be “free” if the GI doctor codes the procedure correctly.

Know the Boundaries of Screening Colonoscopy

The “patient should know when they are eligible for screening colonoscopy regardless of family history or other minor symptoms which might be elicited during questioning and which may not even be indications for diagnostic colonoscopy,” says Weinstein.

Medicare covers screening colonoscopy as follows, according to CMS MLN matters Article SE0613:

• Every ten years for beneficiaries who are do not have a high risk profile for colorectal cancer. The age criteria is 50 years or more. However, remember that the patient should not have undergone a last screening flexible sigmoid­oscopy within past 47 months.
• Every two years for patients having a high risk profile for developing colorectal cancer. There is no criteria set for age here.

Note: “Screening colonoscopy procedures cannot turn into “diagnostic” procedures but they can become therapeutic procedures depending on the findings,” says Michael Weinstein, MD, former representative of the AMA’s CPT^® Advisory Panel.

Example: Suppose a patient underwent his first screening colonoscopy. The provider finds polyps and removes them during the same encounter. This service would be considered as screening colonoscopy even though therapeutic services were also performed; because the initial intent of the procedure was screening, according to the National Colorectal cancer roundtable document ‘Coverage of colonoscopies under the affordable care act’s prevention benefit.’ (http://nccrt.org/wp-content/uploads/NCCRT.pdf)

To report this kind of a scenario, you need to use the appropriate therapeutic colonoscopy procedure CPT^® code. For commercial and Medicaid patients, you may use CPT^® code 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), according to AGA. For Medicare beneficiaries, you may use Healthcare Common Procedural Coding System (HCPCS) codes:

• G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or 
• G0121 (Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk) as appropriate.

Be modifier ready: Do not forget to append modifier 33 (Preventive service) or PT (Colorectal cancer screening test, converted to diagnostic test or other procedure) (for non-Medicare and Medicare carriers respectively), says AGA. “It is important to use the 33 or PT modifier depending on your carrier to let them know the screening turned into a diagnostic colonoscopy,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ.

Pick up Diagnosis Codes the Right Way

You need to be accurate on sequencing of ICD-10 codes for screening colonoscopy that ends up therapeutic, says Brink. There would be two diagnosis codes in your claim:

• First, report the screening ICD-10 CM code Z12.11 (Encounter for screening for malignant neoplasm of colon) listed first on the claim, and
• Next, report the adenoma/polyp ICD-10 CM code based on the exact nature and site of polyp.

Your insurance company would check the primary and secondary diagnosis codes, to know the intent and the results of colonoscopy procedure, says Badal Mangla, PT, CPC, senior coding specialist with TCI.

How Do You Code the Follow up Colonoscopy?

“Subsequent colonoscopy examinations will be defined as high risk or continued low risk based on the initial procedure findings and family history,” says Weinstein. So, you will need to know the risk category of the patient. What’s more, “the appropriate interval between colonoscopy examinations has been determined by consensus of experts and published in the US Multi-Society Task Force on Colorectal Cancer (https://www.guidelines.gov/summaries/summary/38454),” says Weinstein. You may tend to think that this patient is eligible for a screening two years later. “But a two year interval is not indicated unless the patient’s findings were of significant severity,” says Weinstein.

Choose from two possibilities: For screening colonoscopy with no abnormal findings — patient is eligible for next follow-up screening colonoscopy after 119 months or 10 years, says Mangla.

However, if screening colonoscopy leads to therapeutic colonoscopy, i.e. finding and removal of a polyp then the patient would never be considered eligible for screening colonoscopy, (even after ten years of no findings), but instead would be eligible for a covered surveillance colonoscopy, according to AGA’s article (http://www.gastro.org/news_items/colonoscopy-screening-or-surveillance).

“Once there are findings of any type of polyps during a colonoscopy, follow-up colonoscopies are always surveillance,” says Brink. Also, all “follow-up colonos­copies thereafter are considered surveillance regardless of time in between performing them. Some GI physicians may recommend a surveillance colonoscopy in either six months or a year if the biopsies of the polyps indicate a ‘pre-cancerous’ state,” she adds.

Final takeaway: “The USPSTF (U.S. Preventive Services Task Force) has determined that colonoscopy is an effective method of preventing colon cancer morbidity and therefore benefits must be provided by all carriers and Medicare to lower the financial hurdle to obtain screening,” says Weinstein. It will be necessary to educate the patient about the coding and insurance coverage differences between screening and diagnostic procedures.” 

References: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMat­tersArticles/downloads/SE0613.pdf.