Gastroenterology Coding Alert

Order of codes presented in the claims makes a significant difference.

Although Medicare covers a screening flexible sigmoidoscopy, it does not cover any other service provided during the procedure, whereas most non-Medicare payers are the exact opposite. Therein lies a potential for slipups— and a potential loss of significant money—whenever you encounter diagnostic flexible sigmoidoscopy. Here’s a primer to avoid the glitches and ensure the reimbursements.

1. Brush Up on the Screening Flexible Sigmoidoscopy Basics

Providers often perform this service if the patient has signs or symptoms of gastrointestinal disease. In the procedure, the physician uses a flexible endoscope to reach up to 60 centimeters from the anus and view the distal portion of the colon up to the splenic flexure. 

Therefore, this procedure will not be able to give information about any malignancies or polyps in the proximal part of the colon, which a colonoscopy can. However, unlike a colonoscopy, this procedure is simpler to perform due to non-necessity of sedation and less rigorous prep.

Section 4180 of the Medicare Carriers Manual stipulates that Medicare accepts screening flexible sigmoidoscopies once every four years for low risk patients as one of the options for colorectal cancer screening. At least 47 months must have passed since the month in which a prior sigmoidoscopy was performed for screening. In case the patient has already undergone a screening colonoscopy but not a sigmoidoscopy, Medicare will cover the next screening sigmoidoscopy only after a minimum of 10 years (119 completed months) after the colonoscopy. However, this limitation is waived off for patients at high risk for colorectal cancer.

You should use HCPCS code G0104 (Colorectal cancer screening; flexible sigmoidoscopy) to report Medicare screening flexible sigmoidoscopy performed on patients without signs or symptoms of gastrointestinal disease. Report with code 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for a diagnostic flexible sigmoidoscopy performed on patients with signs and symptoms of gastrointestinal disease. 

2. Use Different Diagnosis Codes for Screening and Diagnostic Procedures

When a beneficiary turns up at the clinic for sigmoidoscopy, you may come across one of the two scenarios:

• The patient has no symptom and has presented for screening purposes only. The physician performs the procedure and finds no polyps or tumors. As part of the Affordable Care Act (ACA), Medicare and most third-party payers are required to cover services given an A or B rating by the U.S. Preventive Services Task Force (USPSTF) without a co-pay or deductible. In this case, as long as your physician’s documentation supports it, you will report approved “screening” diagnosis codes to justify the claim. Individual Medicare Administrative Contractors have different sets of allowable diagnosis codes. As these rules keep changing, you should visit your individual carrier for exact rules. Some commonly allowed codes are:

             o V12.72 (Personal history of colonic polyps),
             o V16.0 (Family history of malignant neoplasm of gastrointestinal tract),
             o V71.1 (Observation for suspected malignant neoplasm),
             o V76.41 (Special screening for malignant neoplasms; rectum),
             o V76.51 (Special screening for malignant neoplasms colon),
             o V76.9 (Special screening for malignant neoplasm; unspecified).

The patient has symptoms (e.g., bleeding, diarrhea, severe abdominal pain, etc.) and is advised to have the sigmoidoscopy by the gastroenterologist. The GI detects a growth during a screening flexible sigmoidoscopy but does not perform a biopsy or removal during the session. You can report this encounter with either a “diagnostic” or “therapeutic” procedure code along with the appropriate diagnostic code. If the GI reports 211.3 (Benign neoplasm of colon) or 211.4 (Benign neoplasm of rectum and anal canal) as the diagnostic code and did not perform a biopsy, then he or she would have to report 45330 for the procedure and an ICD-9 code for the relevant symptom along with 211.3 for the polyp finding. 

3. Screening Diagnosis is Primary Even if Screening Becomes Therapeutic

Here’s a third scenario. The patient has no symptom and has presented for screening purposes. The physician performs the procedure and detects polyps/malignancy in the distal colon. He proceeds to remove the polyp(s) with one or more methods. This case is a typical example where a screening visit turns into a therapeutic session. If a lesion or growth is detected that results in a biopsy of the growth, you can report 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple). If you are reporting a removal, depending on the technique used, you can use 45333 (Sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery), 45338 (Sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique), or 45339 (Sigmoidoscopy, flexible; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

Remember: Although you have to report the relevant ICD-9 codes for the identified lesion, you should always remember to add the screening ICD-9 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 Flexible Sigmoidoscopy) was converted to a diagnostic or therapeutic service. This modifier will allow the claim to be processed without a patient co-pay or deductible. For commercial payers, there is a corresponding CPT® Modifier 33 (Preventive Services),” informs Dr. Michael Weinstein, MD, vice president and member of the Board of Managers for Capital Digestive Care.

4. Proper Ordering of Diagnostic Codes Will Make Your Way Easier 

Although you may be reporting all the correct codes and your documentation may be complete, you may still face queries especially when the intent of a visit is screening, and findings result in a diagnostic or therapeutic service. As different payers have their own claims processing system, the ordering of the diagnosis codes may be the difference between a faster payout and an out-of-pocket expense for the patient. To be on the safe side, you should place the appropriate screening diagnosis code in the first position of the claim form and the finding or condition diagnosis in the second place. Verifying your payer’s reporting preferences will stand you in good stead in the long run.