Gastroenterology Coding Alert

Colonoscopies aren’t the only types of colorectal screenings.

Your gastroenterologist probably sees patients for colorectal screenings every week, and those visits can cover a wide range of services. To make sure you know how to report these encounters properly, check out the following four questions and determine whether you can answer them before you read our solutions.

Which Codes Apply to Medicare Patients?

Question 1: An asymptomatic Medicare patient presents for a colorectal cancer screening. Which procedure codes apply to this situation?

Solution 1: Most of the procedure codes that gastroenterologists should bill to Medicare for asymptomatic patients are HCPCS Level II codes. Your first step in determining the right code will be to evaluate whether the patient is considered high risk or not.

High risk: Per CMS, a patient is high risk for colorectal cancer if they have any of the following:

• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
• A family history of adenomatous polyposis;
• A family history of hereditary nonpolyposis colorectal cancer;
• A personal history of adenomatous polyps; or
• A personal history of inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.

You should use the following HCPCS Level II codes on Medicare claims for colorectal cancer screening services for high-risk patients:

• G0104 (Colorectal cancer screening; flexible sigmoidoscopy)
• G0105 (… colonoscopy on individual at high risk)
• G0106 (… alternative to G0104, screening sigmoidoscopy, barium enema)
• G0120 (… alternative to G0105, screening colonoscopy, barium enema)
• 82270 (Screening FOBT (Blood, occult, by peroxidase activity…)
• G0328 (… fecal occult blood test, immunoassay, 1-3 simultaneous)

Average/low risk: When billing a colorectal cancer screening test for an average/low-risk individual, you should choose from these two HCPCS codes:

• G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
• G0122 (… barium enema)

Gastroenterologists should use G0121 when the patient fits the once-every- 10-years interval, and should not be surprised to see a Medicare denial if the prior colonoscopy was less than nine years, 11 months prior. In that case, the physician may not be able to bill the patient for the service unless an Advanced Beneficiary Notice (ABN) was obtained.

Note this exception: Cologuard™ is only billed under CPT^® code 81528 (Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result), but the billing comes from the company which markets the kit, not from the physician’s office; the physician provides a “prescription” (form to fill out as a lab order) and the company then acts on the order and ultimately provides a report to the ordering physician.

Medicare reimburses multiple procedures for the early detection of cancer. The frequency restrictions for these tests depend on the patient’s risk category. Check the following list for deciding eligibility for average risk/ asymptomatic patients (beginning at age 50 years):

• Screening fecal occult blood test (FOBT) — Once every 12 months.
• Screening flexible sigmoidoscopy — Once every 48 months, or 120 months after a previous screening colonoscopy.
• Screening colonoscopy — Once every 120 months, or 48 months after a previous flexible sigmoidoscopy.
• Screening barium enema — Once every 48 months when used instead of sigmoidoscopy or colonoscopy.

Multi-target stool DNA test (like Cologuard™) — Once every three years for people who meet all of these conditions:

1. Between 50 and 85 years of age.
2. They show no signs or symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test.
3. They’re at average risk for developing colorectal cancer, meaning they have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.
4. They have no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.

The frequency rules for high-risk patients (no age restriction) are:

• Screening barium enema — Once every 24 months
• Screening colonoscopy — Once every 24 months

One other option listed in some places as a primary screening test is computed tomography colonography (CTC). However, virtual CTC is not indicated for primary screening. For Medicare, it may be covered under certain conditions such as failed optical colonoscopy or some severe comorbid health conditions.

Are MRI, WCE Tests Payable?

Question 2: Your gastroenterologist occasionally uses MRI or wireless capsule endoscopy (WCE) for colorectal screening. Which code applies?

Solution 2: Unfortunately, those two tests, as well as several others, are non-covered colorectal cancer screening tests under Medicare. The following are all of non-covered services in this category:

• Magnetic resonance imaging (MRI) colonography is considered experimental and investigational for the screening or diagnosis of colorectal cancer, inflammatory bowel disease, or other indications because its value for these indications has not been established.
• WCE (i.e. PillCamTM) is accomplished by encasing video, illumination, and transmission modules inside a capsule the size of a large vitamin pill. WCE is NOT a covered benefit for general screening.
• Septin 9™ blood test.

Know the Diagnosis Codes

Question 3: You see a high-risk patient for a colorectal screening. Which diagnosis codes will demonstrate the high-risk conditions to the insurer?

Solution 3: Although all patients above 50 years of age are eligible for colorectal cancer screening tests even in the absence of any symptoms, a patient must fall into the high-risk category for colorectal cancer to qualify for a screening colonoscopy or screening barium enema before age 50. For a patient to be classified as high risk, you have to use a certain diagnosis. You won’t get paid just because the patient has colorectal cancer screening as a benefit.

To be reimbursed for the screening, check the gastroenterologist’s notes for an accepted diagnosis code denoting the high-risk status of the patient. The following ICD-10 codes are some examples of diagnoses that meet the high-risk criteria for colorectal cancer:

• Z80.0 (Family history of malignant neoplasm of digestive organs)
• Z83.71 (Family history of colonic polyps)
• Z85.00 (Personal history of malignant neoplasm of unspecified digestive organ)
• Z85.810 (Personal history of malignant neoplasm of tongue)

The final determination of an appropriate diagnosis for being at high risk has been left with the local Medicare contractors, however, and the codes that each one will accept can vary significantly.

Differentiate Diagnostic from Screening

Question 4: A patient presents with blood in the stool and the physician schedules a colonoscopy. Which screening codes apply?

Solution 4: None of them. You should never report colorectal screening codes for procedures that qualify as diagnostic services. The HCPCS Level II codes are used when the patient is asymptomatic, regardless of whether the patient is at high risk for colorectal cancer. In this case, the blood in stool is a reason to justify a diagnostic colonoscopy and not a screening one.

Therefore, you should bill the appropriate sigmoidoscopy or colonoscopy procedure codes 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) or 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) for the diagnostic service.

Likewise, fecal-occult blood tests for diagnostic evaluation of symptomatic patients should be billed using the CPT^® code 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations).

If the GI physician converts a screening test into a diagnostic endoscopy due to abnormal findings, you should bill the appropriate CPT^® code with modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) instead of the screening code (for non-Medicare payers, the equivalent is modifier 33, Preventive services).

Gastroenterologists also should ensure that patients referred to them for colorectal screenings are actually asymptomatic. Many times, patients are referred for a screening when they really have symptoms, and those procedures should be coded as diagnostic.