General Surgery Coding Alert

The colonoscopy procedure code may change, but the dx won-t A recent CMS Transmittal has called an end to conflicting guidelines on how to diagnose a screening colonoscopy during which the physician finds a polyp or other abnormality. Coders should find relief in the CMS announcement: The issue of how to report a "screening-turned-diagnostic" has caused confusion for years. Medicare Requires G Codes for Screening Exam For Medicare patients, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for an average-risk patient receiving a screening colonoscopy, or G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for a high-risk patient. Pick your dx: You will assign a V code as the primary diagnosis with any screening colonoscopy. For low-risk patients, you should cite V76.51 (Special screening for malignant neoplasms; colon). When reporting G0105, however, you must supply evidence to support the patient's "high-risk" status. Some diagnoses that Medicare considers high-risk factors for colorectal cancer, and that therefore justify a high-risk screening, include: - V10.05 -- Personal history of malignant neoplasm; gastrointestinal tract; large intestine - V12.72 -- Personal history of certain other diseases; diseases of digestive system; colonic polyps - V16.0 -- Family history of malignant neoplasm; gastrointestinal tract - V18.5 -- Family history of certain other specific conditions; digestive disorders              - 555.0 -- Regional enteritis; small intestine. Note: This is not an exhaustive list of diagnoses that payers may accept for G0105. Check with your individual payer for its guidelines. A Polyp Transforms Procedure Coding When a screening exam uncovers a polyp, you will turn away from the G codes to report the procedure and instead select an appropriate category I CPT code, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Example: The physician begins a screening colonoscopy for an average-risk Medicare patient. She then finds a polyp, which she biopsies. In this scenario, you should choose 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple), without any modifiers, rather than G0121. In other words: If during the screening colonoscopy the physician 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 G0121. Polyps Won't Affect Dx Coding An important point to remember, however -- and the subject of the recent CMS clarification -- is that you should retain the initial V code as the primary diagnosis, even if the physician finds a polyp and performs a diagnostic colonoscopy during the screening exam. "Whether or not an abnormality is found, if a service to a Medicare [...]