Gastroenterology Coding Alert

Watch your endoscopic coding to stay off auditors’ radar screens.

You may think your gastroenterology claims are under a massive amount of scrutiny already, but several recovery audit contractors (RACs) are adding an additional audit focus that will impact you.

Background: Recovery audit contractors (RACs) review Medicare claims for errors and collect a contingency fee based on the amount they recover. Much like MACs, there are different RAC contractors for the various regions in the country, and each one publishes the open issues that it is in the process of auditing.

On November 14, Recovery Audit Contractors Cotiviti and HMS approved a new audit issue involving endoscopy, and on November 27, another RAC -- Performant Recovery -- followed suit.

“Surgical endoscopy includes diagnostic endoscopy,” Cotiviti says in its “Approved Issues” list. “A diagnostic endoscopy HCPCS/CPT^® code shall not be reported with a surgical endoscopy code. If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered shall be reported.”

Performant lists the affected codes as GI-specific services 45330-45338, 45341-45347, 45350-45378, and 45380-45398.

What This Means for You

If your GI practice is diligent about adhering to National Correct Coding Initiative (NCCI) guidelines, this shouldn’t prompt any changes to how you report your services. That’s because the NCCI has long restricted you from reporting surgical and diagnostic endoscopy of the same sites together.

Example: The physician performs sigmoidoscopy for screening purposes. During the procedure, the gastroenterologist detects polyps in the distal colon. The physician removes the polyps using the snare technique. Instead of reporting both 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) and 45338 (…with removal of tumor[s], polyp[s], or other lesion[s] by snare technique), you’ll report only 45338, because it represents the more extensive procedure.

Remember: Although you have to report the relevant ICD-10 codes for the identified polyp, such as K63.5 (Polyp of colon), you should always remember to add the screening ICD-10 codes at the beginning of the claim to indicate that the procedure was initiated as screening procedure.

Also remember to append modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure) to the procedure code. This is a HCPCS modifier used by CMS to indicate that a colorectal screening service, in this case a screening flexible sigmoidoscopy (G0104 if nothing had been found), was converted to a diagnostic or therapeutic service. This modifier will allow the claim to be processed without a patient copay or deductible. For commercial payers, there is a corresponding CPT®  modifier 33 (Preventive Services).

This rule is underscored not only by the new RAC guidance, but also by NCCI edits, which restrict you from reporting the codes together under any circumstances. In addition, a parenthetical note in CPT^® following 45338 states, “Do not report 45338 in conjunction with 45330.”

You are likely to see the same types of restrictions for the other endoscopy codes that the RAC auditors are reviewing, so stay diligent in ensuring that you are only reporting the surgical endoscopy and not the diagnostic code when the physician performs these services together.