Gastroenterology Coding Alert

If you're confused about what constitutes a screening versus a therapeutic colonoscopy and how to order your ICD-9 codes, you're not alone. Three scenarios break down CMS' stance on this tricky subject and help lead to picture-perfect colonoscopy claims.

Scenario 1: A Medicare patient with no gastrointestinal symptoms reports for a screening colonoscopy (or flexible sigmoidoscopy). The gastroenterologist performs the procedure and sees nothing out of the ordinary.

Solution: This is a screening procedure. CMS waives the annual Part B deductible for colorectal cancer screening tests.

For the procedure code, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for an average-risk patient receiving a screening colonoscopy, or G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for a high-risk patient. Use G0104 (Colorectal cancer screening; flexible sigmoidoscopy) if the physician performs a screening flexible sigmoidoscopy.

As for the diagnosis, your primary ICD-9 code should be a V screening code. The only code for individuals not meeting criteria for high risk is V76.51 (Special screening for malignant neoplasms; colon). In other words, you'll use V76.51 for low-risk patients. For high-risk patients, you might use V10.05 (Personal history of malignant neoplasm; large intestine), V10.06 (... rectum, rectosigmoid junction, and anus) or V16.0 (Family history of malignant neoplasm; gastrointestinal tract).

Scenario 2: A Medicare patient with no gastrointestinal symptoms reports for a screening colonoscopy (or flexible sigmoidoscopy). The gastroenterologist performs the procedure and sees an abnormality (such as a polyp or lesion), which he biopsies or removes.

Solution: This is a screening procedure that turned into a therapeutic procedure. You cannot report this procedure as a screening, nor can you waive the deductible.

For the procedure code, you should use the code for the actual procedure and not the G screening code. For instance, if the physician discovers a polyp during the colonoscopy, you should report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple). If the physician performs a flexible sigmoidoscopy, you'll report 45330-45345.

As for the diagnoses, the primary diagnosis should be the screening code: V76.51. Your secondary diagnosis code should reflect the abnormal finding -- for instance, 211.3 (Benign neoplasm of other parts of digestive system; colon). "This way tells the payer that this was a screening colonoscopy and that the physician found a polyp(s) during the exam," says Debora K. Schulte, CPC, medical coder III at UCSD Medical Group Business Services in San Diego.

Helpful hint: Enter a "2" in Box 24E of the CMS 1500 to link the biopsy or polypectomy with the polyp, CMS says.

Suppose your gastroenterologist finds more than a polyp. How would you supply your ICD-9 codes?

Scenario 3: A Medicare patient with no gastrointestinal symptoms comes in for a screening colonoscopy (or flexible sigmoidoscopy). The gastroenterologist performs the procedure and sees an abnormality (such as a polyp or lesion), which he biopsies or removes. He also determines the patient has diverticulosis and internal hemorrhoids.

Solution: Again, this procedure is a screening procedure that turned into a therapeutic procedure. Therefore, you would report 45380 and not the G screening code.

As for the diagnoses, you would report the following sequence:

• V76.51 to show the intention was a screening test

• 211.3 for the polyp

• 562.10 (Diverticulosis of colon [without mention of hemorrhage]) for the diverticulosis and 455.0 (Internal hemorrhoids without mention of complication).

Good idea: "In our practice, we post the first charge as a dummy charge (we call it ADX) with no dollar amount, just a diagnosis," says Gaelin Simson, billing specialist in Lansing, Mich. Example:

CPT------------ DX
ADX----------- V76.51
45380--------- 211.3

Note: You can find the CMS' article here: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0746.pdf. This policy went into effect Jan. 1, 2007.

Advocacy: According to the American Gastroenterology Association (AGA) Web site, the AGA continues to work to "allow the deductible to be waived if a screening procedure results in a therapeutic procedure. AGA believes this was the intent of Congress and the beneficiary should not be penalized."

Congress will consider this for the final Medicare bill, which will be passed before Christmas. Check back with Gastroenterology Coding Alert to see if your coding practice will change in 2008.