General Surgery Coding Alert

Know reason, approach, and completion to capture the pay you deserve.

Coding and modifier changes in the past few years were meant to simplify colonoscopy coding, but some of our readers tell us it has just muddied the water.

Now our experts have a 1-2-3 approach to make your colonoscopy claims crystal clear. Read on to make sure you're in the know.

Step 1: Identify Reason for the Test

Physicians order colonoscopies for either screening or diagnostic purposes. You need to know - and report - the reason for the procedure if you want to code the case correctly.

Screening colonoscopy: Physicians order screening colonoscopies in the absence of signs or symptoms of disease to identify colorectal cancer (CRC) or polyps. Insurers define who is eligible for a covered screening based on risk groups. For instance, Medicare typically covers screening colonoscopies once every 10 years beginning at age 50 for asymptomatic beneficiaries at "normal risk" of developing CRC. Medicare covers screening colonoscopy once every two years, regardless of age, for "high risk" patients demonstrating one of the following situations:

• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
• A family history of familial adenomatous polyposis (FAP)
• A family history of hereditary nonpolyposis colorectal cancer
• A personal history of adenomatous polyps
• A personal history of colorectal cancer
• Inflammatory bowel disease, including Crohn's Disease, and ulcerative colitis.

Diagnostic colonoscopy: The provider performs a diagnostic procedure when a patient presents with symptoms that require investigation, says Michael Weinstein, MD, former representative of the AMA's CPT^® Advisory Panel. This might include issues like chronic diarrhea, significant hematochezia, or a questionable abnormality noted on an imaging study, he says. Assuming that an office note or pre-procedure note details the patient's complaint, the subsequent procedure will be a diagnostic colonoscopy. This is true even if the patient has never had a prior routine screening colonoscopy and mentions that the insurance company representative told the patient that the procedure would be "free" if the physician codes the procedure correctly.

Step 2: Choose the Right Diagnosis Code

The op note should document the reason for the test with an appropriate ICD-10 code. For screening tests, the appropriate initial code you should report is Z12.11 (Encounter for screening for malignant neoplasm of colon).

If the patient has factors that indicate high-risk for developing CRC, you'll have to report an appropriate ICD-10 code in addition to Z12.11 to demonstrate medical necessity for more frequent colonoscopy. For instance, you might code Z12.11 followed by Z80.0 (Family history of malignant neoplasm of digestive organs) or Z86.010 (Personal history of colonic polyps).

If the surgeon is performing a diagnostic colonoscopy, you should code the symptoms that led to the procedure, such as R19.7 (Diarrhea, unspecified) and K92.1 (Melena).

Findings: When coding the case, you should report any findings, such as a polyp of the descending colon (D12.4, Benign neoplasm of descending colon). "Remember that you should always complete diagnosis coding after the pathology report is available," says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebr.

Key: If the ordered colonoscopy was for CRC screening, you should still code first the screening diagnosis (Z12.11), followed by any additional ICD-10 codes for findings.

Step 3: Chose the Right Procedure Code

Choosing the proper procedure code usually means picking the CPT^® code that best describes the service your surgeon performs. But that's not the only factor you need to consider when coding colonoscopies. You must also take into account the payer and the reason for the test if you want to make sure you report the correct code.

Medicare: If the surgeon performs a diagnostic colonoscopy for a Medicare beneficiary, you should report the appropriate CPT^® code that describes procedure, such as 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]). But you should report screening colonoscopies for Medicare beneficiaries using one of the following codes:

• G0105 (Colorectal cancer screening; colonoscopy on individual at high risk)
• G0121 (Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk).

For non-Medicare payers, you'll report a screening or diagnostic colonoscopy that involves no further intervention using 45378.

Whether for Medicare or non-Medicare payers, if the surgeon finds something during the colonoscopy that results in further intervention, you should use the appropriate CPT^® code, such as one of the following:

• 45380 (... with biopsy, single or multiple)
• 45384 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps).

Step 4: Modify Anything Unusual

When a screening colonoscopy results in findings that require therapeutic intervention, such as removing a polyp or taking a biopsy, you need a way to communicate the situation to the 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 for years, as patients who qualified for a "free" screening colonoscopy suddenly found themselves facing extensive procedure charges. Fortunately, you now have two different modifiers to describe the situation so payers can appropriately cover the screening test. Append the following CPT^® modifier for non-Medicare payers, and the following HCPCS Level II modifier for Medicare:

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

"It is important to use the 33 or PT modifier depending on your carrier to let them know the screening turned into a diagnostic colonoscopy," says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ.