General Surgery Coding Alert

See how one little modifier can help.

If just thinking about colonoscopy coding gives you a headache because of all the convoluted coverage and billing rules, you’re not alone. 

But if you follow the logic of this one simple case, along with our expert’s explanations of code options for variations, you’ll be prepared to face any colonoscopy case your surgeons throw at you.

Scenario: A non-Medicare patient has a family history of colon cancer and presents for her second screening colonoscopy five years after her initial procedure. During the screening, the surgeon finds and excises a polyp, which pathology confirms as benign.

Look at the following four steps and you’ll make sure to get the best possible payer coverage — for your surgeons and for your patients.

Assign Risk Level

Frequency rules for screening colonoscopy often depend on whether the patient is “high risk” or normal risk for colon cancer. Different payers may have their own rules, but many payers follow Medicare rules for screening colonoscopy.

If the payer in this scenario follows Medicare rules, the payer will cover a screening colonoscopy every two years, regardless of patient age, because of the fact that the patient has a family history of colon cancer. 

Alternate: For normal risk patients, Medicare and payers that follow Medicare rules cover a screening colonoscopy once every 10 years, beginning at age 50, but not within 47 months of a prior screening flexible sigmoidoscopy.

Remember: Some payers follow Medicare coverage rules, but not all do, so you should check with individual payers for frequency rules. 

Get the Diagnosis Right

Despite the fact that the patient is at “high risk” for colon cancer, she has no current diagnosis or symptoms that makes this a diagnostic colonoscopy. That means you need to assign diagnosis code(s) to indicate that this is a screening, and that the patient is in the high risk group. 

Do this: Always list the screening diagnosis code first: V76.51 (Special screening for malignant neoplasms; colon). Because the patient has a family history of colon cancer, you should additionally list V16.0 (Family history of malignant neoplasm of gastrointestinal tract) which will show medical necessity for a high risk screening for Medicare and possibly other payers to justify a second colonoscopy within 10 years of the first. 

Alternate: The following list demonstrates some other diagnoses that would justify colonoscopy for high-risk colon cancer screening: 

• V10.05 — Personal history of malignant neoplasm of large intestine
• V10.06 — Personal history of malignant neoplasm of rectum rectosigmoid junction and anus
• V12.72 — Personal history of colonic polyps
• V18.5 — Family history of digestive disorders
• 555.x — Regional enteritis (includes Crohn’s disease)
• 556.x — Ulcerative enterocolitis.

Final diagnosis: Because the surgeon removed a polyp, which pathology confirmed as benign, you should list 211.3 (Benign neoplasm of Colon) as the final diagnosis. You need to keep the ordering diagnosis as the first diagnosis to show that the surgeon initiated the procedure as a screening test.

Choose the Proper Procedure Code

Because the surgeon finds and removes a polyp, you should narrow your choice to 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) or 45385 (… with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). 

Alternate: If the surgeon hadn’t removed a polyp or performed any additional service beyond a screening colonoscopy, you would report 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]) for this non-Medicare patient.

Medicare is different: When screening a patient covered by Medicare, you should rely on two codes: G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk), for patients “not meeting criteria for high risk” — or typically the average risk patient, says Michael Weinstein, MD, a physician at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT® Advisory Panel.

Caution: You shouldn’t use G0105 or G0121 if the surgeon finds and removes tissue such as a polyp or biopsy during the colonoscopy. In that case, you’ll need to turn to the appropriate CPT® codes to describe the procedure. 

Look for Modifiers

When a screening colonoscopy becomes a diagnostic procedure, as it did in this case, you’ll need to use a modifier to ensure coverage for the patient. 

What’s at stake: For most payers, a screening colonoscopy is not subject to the patient’s deductible and copay, but a diagnostic colonoscopy is. Without proper modifier use, your patient might get stuck with a bill for a diagnostic test.

Most non-Medicare payers ask that you use modifier 33 (Preventive services) to indicate that the physician performed the colonoscopy as a colon cancer screening. You should append modifier 33 (Preventive services) to the procedure code for the surgeon’s work.

For Medicare, you should append modifier PT (Colorectal cancer screening test, converted to diagnostic test or other procedure) to the surgical code such as 45384.