Gastroenterology Coding Alert

Look at new ‘decision tree’ to get clear choices.

How to code a colonoscopy that a physician doesn’t complete has been a burning question for a long time. You may have resorted to different solutions to the problem such as the use of modifier 52 (Reduced services), modifier 53 (Discontinued procedure), or not coding a colonoscopy at all but instead reporting a sigmoidoscopy. However, the debate has been almost conclusively settled by CPT® 2015 by issuing a new “colonoscopy decision tree.” Now coders have instruction directly from the AMA to clarify your coding choices in these circumstances.

Choose Sigmoidoscopy Before Splenic Flexure

If your surgeon preps the patient for a colonoscopy, either diagnostic 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) or therapeutic (45379-45398, Colonoscopy, flexible; …) but does not advance the scope to the splenic flexure, you shouldn’t report a colonoscopy code, according to the CPT® decision tree.

Do this: Instead of a colonoscopy, report the appropriate flexible sigmoidoscopy code — 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) for diagnostic, or 45331-45347 (Sigmoidoscopy, flexible;…) for therapeutic procedures involving additional work such as tumor ablation.

To the Cecum — Don’t Modify Codes

CPT® 2015 defines a colonoscopy as “the examination of the entire colon, from the rectum to the cecum …” If your surgeon advances the scope all the way to the cecum, you should report the appropriate therapeutic or diagnostic colonoscopy code (45378-45398) without a modifier.

Alert: The initially published CPT® 2015 manual erroneously states in the decision tree that you should use modifier 52 for therapeutic colonoscopies that proceed to the cecum. “But presenters at the AMA symposium identified the error and alerted coders to cross out that instruction in the decision tree,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, internal audit manager at PeaceHealth in Vancouver, Wash. Look for the change in the quarterly AMA publication of CPT® Errata.

In Between — Choose 52 or 53

What if the surgeon succeeds in advancing the scope beyond the splenic flexure, but does not proceed all the way to the cecum?

You’ll need a modifier, in these cases, but which modifier depends on the circumstances, according to the CPT® colonoscopy decision tree.

Do this: For diagnostic colonoscopies advanced somewhere between the splenic flexure and cecum, append modifier 53 to 45378. For therapeutic colonoscopies advanced somewhere between the splenic flexure and cecum, append modifier 52 to the appropriate code in the range 45379-45398.