Gastroenterology Coding Alert

Know what to report when 45330 turns therapeutic.

Are you sure you are getting optimal reimbursement for your sigmoidoscopy screening procedures? Differences in payment policies between Medicare and private payers, could lead to slipups, and a loss of revenue that you cannot afford. Take the guesswork out of coding for sigmoidoscopies and learn how to bill the claims when procedures turn diagnostic to therapeutic midway.

What is Screening Flexible Sigmoidoscopy?

This is a procedure to examine the lower intestinal tract, where the physician introduces a flexible endoscope in the anus to view the distal portion of the colon up to the splenic flexure. Usually, the scope is able to reach up to 60 centimeters within the colon. This is a relatively simple and convenient procedure to perform, and gives information about any malignancies or polyps in the part of the colon distal to splenic flexure.

You may 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. Most commercial payers also accept this code. An alternative code to use would be G0106 (Colorectal cancer screening; alternative to G0104, [screening sigmoidoscopy], barium enema), if the provider employs a barium enema in the procedure.

You may report 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), for a diagnostic flexible sigmoidoscopy performed on patients with signs and symptoms of gastrointestinal disease.

Devise Your Strategy Based On History

According to the frequency rule by National Comprehensive Cancer Network (NCCN) Guidelines^®, as mentioned by the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA) and American Society for Gastrointestinal Endoscopy (ASGE) in their joint document (https://gi.org/wp-content/uploads/2016/03/2695-007COM_16-1-CPT-Coding-Updates_v3.pdf); annual flexible sigmoidoscopy is required, if a person demonstrates a family history of familial adenomatous polyposis (FAP). If the person is a genetic carrier, annual flexible sigmoidoscopy or colonoscopy should begin at age 10 to 15. If the person does not know of his genetic status, he should still undergo a flexible sigmoidoscopy or colonoscopy screening annually beginning at age 10 to 15 years, and continue until the age of 24 years. This is followed by screening once in two years till the age of 34, once every three years till age 44, and repeated every three to five years subsequently.

Medicare and most third-party payers cover these services without a co-pay or deductible, according to the U.S. Preventive Services Task Force (USPSTF). You must, however, submit payor approved screening diagnosis codes to justify the claim. Because individual Medicare Administrative Contractors have different sets of allowable diagnosis codes, it would be wise to contact your individual carrier for exact information. Some of the approved codes are:

• Z86.010 (Personal history of colonic polyps)
• Z80.0 (Family history of malignant neoplasm of digestive organs)
• Z03.89 (Encounter for observation for other suspected diseases and conditions ruled out)
• Z12.12 (Encounter for screening for malignant neoplasm of rectum)
• Z12.11 (Encounter for screening for malignant neoplasm of colon)
• Z12.9 (Encounter for screening for malignant neoplasm, site unspecified)

“There are rules about the interval between screening tests which apply to the coverage of procedures like Flexible Sigmoidoscopy,” says Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel. “According to CMS rules, the interval between screening sigmoidoscopy exams must be at least four years to be paid as a preventive health benefit.”

What to Do if Screening Procedure Turns Therapeutic

If a screening process results in a finding and the provider performs a therapeutic procedure in the same session, you may choose from of therapeutic sigmoidoscopy procedure code range 45331-45342 (Sigmoidoscopy, flexible…)

For example: A patient has no symptoms and has presented for screening purposes. The physician performs the procedure and detects polyps in the distal colon. If the provider performed a biopsy of the growth, you may report 45331. If he proceeds to remove the polyp(s) with one or more methods; depending on the technique used:

• For removal using hot biopsy forceps or bipolar cautery use 45333
• For removal by snare technique report 45338
• For removal by hot biopsy forceps, bipolar cautery or snare technique report 45339

Remember:  Although you have to report the relevant ICD-10 codes for the identified polyp, say 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,” says Weinstein. “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).”

Another lesson: “Ensure you are only coding for the sigmoidoscopy and not a colonoscopy,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ. “Be sure to read the medical documentation to accurately report the procedure-sigmoidoscopy. If the medical documentation indicates both sigmoidoscopy and colonoscopy, then [you must code] both procedures.”

Final takeaway: Even if you are impeccable in the codes you report, payers may still ask questions if the intent of the visit was screening, and it ended up with a diagnostic or therapeutic procedure. Play it safe by assigning the appropriate screening diagnosis code in the first position of the claim form and the finding or condition diagnosis in the second spot. Also remember to verify your payer’s reporting preferences for these services.