Gastroenterology Coding Alert

Question: We saw a Medicare patient for a screening colonoscopy, and the gastroenterologist found something suspicious during it, so the colonoscopy switched from screening to diagnostic. The patient was unhappy because she then had to pay toward her deductible, which she was not expecting to be necessary, since deductibles are waived for screening colonoscopies. Do you have sample language we can use to explain this to patients so they don't get upset?

Codify Subscriber

Answer: Your communication with the patient may not be necessary in this situation, assuming you sharpen your communication with the Part B payer.

Here's  why: Most payers cover the complete cost of a screening colonoscopy as a preventive-care measure for patients who meet the screening criteria. But payers cover a diagnostic/therapeutic colonoscopy subject to patient deductibles and copayments prescribed in the policy.

This situation created problems, as patients who qualified for a "free" screening colonoscopy suddenly find themselves facing extensive procedure charges. Fortunately, you have two different modifiers to describe the situation so payers can appropriately cover the screening test. Append the CPT^® modifier for non-Medicare payers, and the HCPCS Level II modifier for Medicare:

• 33 (Preventive service)
• PT (Colorectal cancer screening test; converted to diagnostic test or other procedure).

Modifier PT indicates that a colorectal screening service was converted to a diagnostic or therapeutic service. The counterpart for a non-Medicare patient is modifier 33. The ICD-10 code for colon cancer screening, Z12.11 (Encounter for screening for malignant neoplasm of colon), should ordinarily be the first code, reflecting the intention of the procedure being screening.

The importance of these modifiers to the patient is that the deductible for the procedure is waived for Medicare, while both deductible and copay are waived for the commercial payer patients. This reflects the preventive service benefits, which under the Affordable Care Act, allow those patient responsibilities to be waived. Without the modifier, there is a risk the patient gets charged for both deductible and copayment.

Therefore, if you communicate appropriately with the payer by appending the proper modifier, you will spare yourself the stress of having to collect from the patient in cases when the modifier will allow the deductible to be waived.