General Surgery Coding Alert

Medicare Coverage:

Correctly File Screening Colonoscopy Claims with These Tips

Published on Fri Feb 18, 2022

CMS to phase out coinsurance for screenings that turn diagnostic.

When your surgeon performs a screening colonoscopy or flexible sigmoidoscopy, you need to follow certain coverage and billing rules to secure your patient’s preventive service benefit of 100 percent coverage.

But what happens when the surgeon finds and removes a polyp or other tissue of concern? That circumstance can leave the patient holding the bag for 25 percent of the bill instead of paying nothing.

Relief: The Centers for Medicare and Medicaid Services (CMS) aims to fix the problem by phasing out coinsurance costs for CRC screening tests that result in additional services such as polyp removal.

Read on to learn the details of the CMS relief plan and tips for mastering the coding and billing rules for screening colonoscopies or flexible sigmoidoscopies.

Look to MPFS Final Rule

CMS used the Medicare Physician Fee Schedule (MPFS) final rule for 2022 to formalize how the agency will phase out the coinsurance payments that beneficiaries face when a CRC screening scope procedure turns diagnostic.

Old way: When a CRC screening scope procedure resulted in a biopsy or removal of a lesion or growth, Medicare did nor classify the procedure as a screening service but considered it diagnostic and charged the patient a coinsurance amount.

New way: According to the final rule, “When a planned colorectal cancer screening test, that is, screening flexible sigmoidoscopy or screening colonoscopy test, requires a related procedure, including removal of tissue or other matter, furnished in connection with, as a result of, and in the same clinical encounter as the screening test, it is considered to be a colorectal cancer screening test.”

Payment: The final rule also states, “Medicare will reduce, over the over a period of years, the percentage amount of coinsurance for which the beneficiary is responsible. Ultimately, for services furnished on or after January 1, 2030, the coinsurance will be zero.”

Specifically: For services on or after January 1, 2022, the coinsurance amount … shall be equal to a specified percent (i.e., 20 percent for CY 2022, 15 percent for CYs 2023 through 2026, 10 percent for CYs 2027 through 2029, and zero percent beginning CY 2030.

When a screening colonoscopy turns diagnostic, use the following two tips to correctly code the case and secure your surgeon’s pay and the patient’s best coverage.

Tip 1: Get the Diagnosis Right

When you’re coding a CRC screening colonoscopy or flexible sigmoidoscopy, you may have several ICD-10-CM codes to consider.

Even when the surgeon removes a lesion and the pathologist diagnoses a specific condition, you should always list first the screening diagnosis code, Z12.11 (Encounter for screening for malignant neoplasm of colon).

If the surgeon removes a polyp and the pathology report indicates a diagnosis of hyperplastic colon polyp, “you should also report K63.5 (Polyp of colon),” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Tip 2: Skip ‘G’ Codes With Lesion Removal

You should normally report a screening colonoscopy or flexible sigmoidoscopy procedure to Medicare using one of the following HCPCS Level II codes:

G0104 (Colorectal cancer screening; flexible sigmoidoscopy)
G0105 (Colorectal cancer screening; colonoscopy on individual at high risk)
G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)

But when the surgeon adds a service beyond just “looking,” you need to use a more specific code instead. For instance, you might report a colonoscopy with additional work with one of the following codes, or some other code, depending on the specifics of the case:

45380 (Colonoscopy, flexible; with biopsy, single or multiple)
45384 (… with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
45385 (… with removal of tumor(s), polyp(s), or other lesion(s) by snare technique)

Modifier: Don’t forget to add modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) to identify these as preventive services,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^®Editorial Panel member in Pasadena, California

Caveat: Medicare is the only payer that recognizes modifier PT. For other payers, you may need to use modifier 33 (Preventive Services) instead.