Gastroenterology Coding Alert

Question: My gastroenterologist performs a screening colonoscopy on a patient. We do not have enough staff to verify the patient's benefits before the procedure. We bill the colonoscopy as diagnostic; 90 percent of patients with this insurance

don't have benefits for a screening. But, after insurance pays, the patient wants us to bill the procedure as a screening because her insurance will pay 100 percent. We send in corrected claims so the patient doesn't have to pay the 10 percent.

What should we be doing differently?

Alabama Subscriber

Answer: If the physician performed a colonoscopy to screen for cancer, you have to code it that way, and not to suit the patient's desires or insurance coverage. To do otherwise is to risk a charge of fraud.

The proper codes for a colonoscopy screening for Medicare patients are:

• G0105 ��" Colorectal cancer screening; colonoscopy on individual at high risk

• G0121 ��" Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.

The proper code for a colonoscopy screening for patients whose insurance does not adhere to Medicare coding rules is 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or

washing, with or without colon decompression [separate procedure]).

Exception: If, during the screening colonoscopy, the physician detects a lesion or growth that results in a biopsy or removal of the growth, you should bill the appropriate diagnostic procedure, such as 45380 (Colonoscopy, flexible, proximal to

splenic flexure; with biopsy, single or multiple) rather than G0121.

You should retain the initial V code -- V76.51 (Special screening for malignant neoplasms; colon) -- as the primary diagnosis, even if the physician finds and removes a polyp during the exam. Likewise, a patient who presents with a symptom

that requires a colonoscopy must be coded diagnostic, not screening.