Gastroenterology Coding Alert

Hint: Do not use the modifier PT when the service began as a diagnostic procedure.

Although the coding of a screening colonoscopy is a straightforward process and involves only a couple of relevant codes, problems arise when the same screening procedure turns diagnostic or therapeutic during the course of the procedure. Earlier, this conversion to a therapeutic procedure meant the patient was responsible for a co-pay and deductible, but Medicare modifier PT ( Colorectal cancer screening test converted to diagnostic test or other procedure) has helped solve that part of the problem.

Learn how to use the modifier PT to smoothen your colonoscopy reimbursement wrinkles.

Get to Know Modifier PT Basics

According to WPS Medicare (Michigan and Indiana), modifier PT should be used with a colorectal cancer screening test which led to a therapeutic procedure.

Modifier PT tells the MAC contractor that the service started as a screening procedure (e.g. G0105 [Colorectal cancer screening; colonoscopy on individual at high risk], G0121 [Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk]) but an abnormality was found and the procedure became diagnostic or therapeutic.

When appended to your procedure code, the modifier will indicate to Medicare to waive the deductible for a diagnostic procedure.

Modifier PT and G Codes Don’t Gel

Once the physician indicates that the screening procedure has turned diagnostic, you’ll bill only the diagnostic colonoscopy code, and not the screening code (G0104-G0106, G0120-G0121). Not only is this correct coding, but it’s also the only way you can use modifier PT.

According to WPS Medicare:

• Modifier PT should only be appended when a service began as a colorectal cancer screening test and then was moved to therapeutic test due to findings during the screening
• Practitioners should append the modifier to the therapeutic procedure code that is reported instead of the screening colonoscopy or screening sigmoidoscopy HCPCS code
• Append to surgical procedure codes in the range: 10000 to 69999 or G6018-G6028

Therefore, you should not append modifier PT to G codes such as G0104-G0121.

According to Medicare rules, you should not use the Modifier PT when the service began as a diagnostic procedure.

For example: During a screening colonoscopy for an average risk Medicare patient, the physician discovers several polyps. He removes the polyps (which are later determined to be benign) during the same procedure using a snare technique. In this case, you should bill the colonoscopy with polyp removal via snare technique (such as 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s], by snare technique) with modifier PT appended to 45385.

Note: Other than the Medicare HCPCS codes, you can also report the colon screening with CPT® codes 45399 (Unlisted procedure, colon) or 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen [s],  by brushing or washing, when performed [separate procedure]) for commercial payers.

Ply the ‘Z’ Codes But With Care

Because your colonoscopy started out as a screening procedure, your diagnosis code should reflect both the screening nature of the visit and the actual condition that the physician treated.

According to CMS, “CMS advises that, whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-10 code for the screening examination. Indicate the secondary diagnosis using the ICD-10-CM code for the abnormal finding (polyp, etc.).” You can read this article at www.cms.gov/MLNMattersArticles/downloads/SE0746.pdf.

The recently discontinued ICD-9 V codes are V16.0 (Family history of malignant neoplasm of gastrointestinal tract), V76.41 (Screening for malignant neoplasms of the rectum), V76.51 (Special screening for malignant neoplasms, colon), V76.52 (Special screening for malignant neoplasms small intestine), V76.89 (Special screening for other malignant neoplasms), and V76.9 (Screening for unspecified malignant neoplasms).

Most offices are familiar with the old V codes but offices should cross over to the following addresses in ICD-10 and get to know them as well as you knew the prior system:

• V16.0 à Z80.0 (Family history of malignant neoplasm of digestive organs)
• V76.41 à Z12.12 (Encounter for screening for malignant neoplasm of rectum)
• V76.51 à Z12.11 (Encounter for screening for malignant neoplasm of colon)
• V76.52 à Z12.13 (Encounter for screening for malignant neoplasm of small intestine)
• V76.89 à Z12.89 (Encounter for screening for malignant neoplasm of other sites)
• V76.9 à Z12.9 (Encounter for screening for malignant neoplasm, site unspecified)

Therefore, in the example described above, the claim would appear with Z12.11 as the primary diagnosis. You should then append the appropriate diagnostic modifier to your claim. For example, if the physician removes a benign polyp from the colon, you’ll report D12.6 (Benign neoplasm of colon, unspecified). The prior ICD-9 code was 211.3 (Benign neoplasm of colon).

Waive Deductible for Anesthesia Associated With Screening Colonoscopy

CMS has removed any coinsurance and deductible payments for anesthesia associated with screening colonoscopy. The agency has expanded the range of services to which the modifier PT applies to include lower GI endoscopy anesthesia CPT® code 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum).

Effective since Jan. 1, 2015, whenever anesthesia service 00810 is performed in conjunction with screening colonoscopy services G0105 or G0121, coinsurance and deductible will be waived for anesthesia service 00810 when modifier 33 is entered on the anesthesia claim. When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia code 00810 should be submitted with the PT modifier and copay and deductible for surgical services related to the colonoscopy / sigmoidoscopy on the same day as the screening test will be waived.

This change addresses concerns that Medicare Administrative Contractors were denying claims for anesthesia for colonoscopies submitted with modifier PT, even though CMS directed providers to report screening colonoscopies that become diagnostic or therapeutic with that modifier.