Gastroenterology Coding Alert

Question: A patient, with a personal history of colon polyps, comes to the provider for a colon screening. On performing the colonoscopy, the provider finds it to be a normal colon. How do we code this procedure?

Iowa Subscriber

Answer: Having a history of colon polyps, the patient automatically comes into the category of high risk. Therefore the ICD-10-CM code to report would be Z86.010 (Personal history of colonic polyps). As for the CPT^® code, for a non-Medicare patient you may report 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) along with modifier 33 (preventive service) to indicate that the provider performed a preventive service. If the patient is a Medicare patient then the correct code for this patient is G0105 (Colorectal cancer screening; colonoscopy on individual at high risk).