Gastroenterology Coding Alert

Also: review the differences between modifiers 52 and 53.

Colonoscopy coding, while commonplace among gastroenterology coders, is often a source of confusion. There are a lot of places along the way that coding can go awry.

In this article, we’ll helping you sort through three situations that can befuddle even experienced coders. Shore up your colonoscopy coding with this helpful guide.

1. Keep Pre-Op E/M Rules In Mind

The first place colonoscopy coding can stir up trouble is during the pre-op visit. Commonly, coders get confused about if and when they can report the pre-op evaluation and management (E/M) service separately. For example, when a patient comes in the day before the colonoscopy for their pre-op evaluation, can you bill another E/M even if nothing has changed from that first encounter?

Under Medicare rules, once the provider makes the decision for the procedure, you should not separately bill any preoperative visits related only to the procedure. In other words, the prescreening visits don’t usually present new information that warrants the need for an E/M service.

Exception: If the patient’s situation changes between the first and second visits before surgery, you might be able to make the case for billing another office/outpatient E/M.

For instance, if the patient develops a serious medical condition that is unrelated to the reason for the procedure but could impact the outcome, the doctor may perform additional services that increase the level of medical decision making (MDM) and, if properly documented, could allow you to bill a separate E/M visit. An example of this might be the sudden onset of severe symptoms of liver disease like jaundice, abdominal pain, and swelling during a pre-colonoscopy visit. This is a serious condition that could be considered unrelated to the need for a colonoscopy and would therefore require a completely separate E/M service.

Modifier alert: Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) when situations like this result in a separately billable E/M. Documentation must clearly support the separate service. “We need a robust paragraph of evaluation and management,” says Jeffrey Lehrman, DPM,

FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

2. Practice Proper Modifier Use in Poor Prep Situations

Let’s say your gastroenterologist performed a screening colonoscopy and was able to advance to the cecum. However, due to poor prep which limits visualization, the provider could not continue, and the patient will therefore need to return at a later date. Can you still code the procedure?

Yes, you can. The provider started the procedure and attempted to follow through, so it’s important they be reimbursed for the work they were able to do. However, since they couldn’t follow through to the end of the procedure, the claim needs to reflect that. This is a situation where you’d need to append modifier 53 (Discontinued procedure) to the 45378 code, even if a G code, such as G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) or G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) would have been billed for a complete but negative screening colonoscopy for a Medicare patient. Using modifier 53 in this scenario stops the clock and allows the patient a full screening benefit when they return for the complete procedure.

This is because in the case of colonoscopies, you can append modifier 53 without the patient well-being being a factor.

Remember: Modifier 53 (Discontinued procedure) is often misunderstood, partly because of its similarity to modifier 52 (Reduced services). Essentially, when you use modifier 53, you’re identifying a situation where the physician terminates the procedure due to extenuating circumstances or circumstances that may threaten the patient’s well-being. This differs from modifier 52, which you should use when the physician completes the procedure but elects to reduce a portion of the service or procedure, though not because the patient’s well-being is in question.

Documentation alert: When coding with modifier 53 in a poor colonoscopy prep situation, you should provide easy-to-read, clear, concise documentation explaining in specific detail what the procedure accomplished, what percent your GI completed, the patient’s condition, the extenuating circumstances that caused the discontinuation, and the detailed operative report. Be sure to check with your payers because some may refuse to pay for this modifier or have particular requirements for its use.

3. Correctly Code the Screening That 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,” says Kristie Harris, RHIT, CPC, coding educator for a hospital system in Oklahoma.

Payers that do not accept it may instead require modifier 33 (Preventive services), 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 a 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,” Harris explains.

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 says. 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 an additional service or procedure.