Gastroenterology Coding Alert

Question: If a patient with a pre-existing diagnosis receives a colonoscopy, should we report a diagnostic or screening service?


Pennsylvania Subscriber


Answer: The solution to this problem isn't always clear-cut: Certain conditions could call for either a diagnostic (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]) or a screening (G0105, Colorectal cancer screening; colonoscopy on individual at high risk) colonoscopy.

Crohn's disease, ulcerative colitis or other bowel disease could justify a diagnostic colonoscopy, but only under certain circumstances. Specifically, carriers will impose time-based criteria for diagnostic colonoscopies for patients with these conditions.

For example, WPS Medicare Administrators and many other carriers will only cover diagnostic colon-oscopies for patients with Crohn's or ulcerative colitis if they-ve had the condition on their entire colon for eight years or more, or on the left side of the colon for 15 years or more.

WPS will also cover diagnostic colonoscopies for unexplained rectal bleeding, diarrhea accompanied by weight loss, or chronic inflammatory bowel disease of the colon if a more precise diagnosis or a determination of the disease's extent will influence the physician's management, among other conditions.

Bottom line: You-ll have to check your specific insurer's criteria for billing colonoscopies for patients with pre-existing conditions, and you-ll have to keep close track of how often you report colonoscopies (whether screening or diagnostic) for all patients.