General Surgery Coding Alert

Polyp Transforms Screening to Diagnostic

When the surgeon performs a diagnostic, non-screening colonoscopy, you should turn away from the G codes. But what if the colonoscopy begins as a screening and ends up diagnostic?

Question: The surgeon begins a screening colonoscopy for an average-risk Medicare patient. She then finds a polyp, which she biopsies. In this scenario, which of the following code(s) choices would you use to describe the encounter?

You should choose 45380 alone, without any modifiers, when a screening exam becomes diagnostic, according to two experts.

Expert 1: "I would report just 45380," Covington says.

Explanation: "Once the polyp is visualized and biopsy performed, the diagnosis would have to change from V76.51 (Special screening for malignant neoplasms; colon) to 211.3 (Benign neoplasm of other parts of digestive system; colon)," Covington says.

Expert 2: "If during the screening colonoscopy, the surgeon detects a lesion or growth that results in a biopsy or removal of the growth, you should bill, and be paid for, the appropriate diagnostic procedure [45380] rather than code G0121," says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers.

Some Private Payers May Use G Codes

If your surgeon performs a screening colonoscopy on a non-Medicare patient, you should 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]), Covington says.

When coding screenings for non-Medicare patients, you can stick with 45378 whether the patient is at high or low risk for colorectal cancer. With private payers, the risk category is not as vital as when reporting with Medicare.

Exception: Pfaff says she uses 45378 for a simple screening for all non-Medicare patients - "unless there is a contract with a payer that states that they [the payer] utilize Medicare G codes. If there is not a contract, report the CPT code as 45378 and an appropriate screening ICD-9 code [V76.51], since many insurances have preventive benefits," she says.

Diagnosis Tip: If your non-Medicare patient has one of the V-code diagnoses listed above (V10.05, V12.72, etc.), go ahead and include the diagnosis on your private-payer 45378 claim. Even for non-Medicare patients, these diagnoses can provide valuable and more complete information about the patient and his condition.