Gastroenterology Coding Alert

Question: A Medicare patient had an average-risk screening colonoscopy. The gastroenterologist biopsied what he thought was a fatty ileocecal valve, but it was normal. The pathology report reads "biopsies ileocecal valve: no pathologic findings."

Should I report this as an average-risk screening colonoscopy (G0121) or a colonoscopy with biopsy (45380)? Also, which diagnosis code should I use? I am confused on how to report something other than a polyp being biopsied and normal biopsy samples.

Nevada Subscriber

Answer: Whenever a biopsy is performed during a screening, you should report the procedure as a colonoscopy with biopsy (45380), not a screening colonoscopy. The Medicare Carriers Manual (MCM) section 4180.2(D) states that whenever "a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than G0121."

The MCM does not specify what the pathology of the biopsy sample had to be, only that a biopsy or removal had to be performed. What matters to Medicare is that the gastroenterologist performed a biopsy.

Your diagnosis code should also be based on what the gastroenterologist thought was being biopsied. In this situation, an appropriate primary diagnosis code to report the biopsy of the ileocecal valve is 569.89 (Other specified disorder of intestine). If instead of a fatty ileocecal valve, your gastroenterologist biopsied what was believed to be a colonic polyp, you should report a primary diagnosis of 211.3 (Benign neoplasm of the colon) even if the pathology report comes back as normal.

If your gastroenterologist had other findings, such as hemorrhoids (455.6) or diverticulosis (562.1x), but did not perform a biopsy, the procedure would remain a screening colonoscopy. The primary diagnosis in this situation would be V76.51 (Special screening for malignant neoplasms, colon). You may report the findings as secondary diagnoses.