Understanding HCFAs Special Coding Status Is Key to Billing Colonoscopies Correctly
Published on Wed Nov 01, 2000
Colonoscopy billing presents a challenge for general surgeons and their coders because payment guidelines for these procedures are unique. For instance, when the surgeon performs a diagnostic colonoscopy (45378) but cannot complete the procedure, the Health Care Financing Administration (HCFA) instructs coders to append modifier
-53 (discontinued procedure) to 45378. Normally, modifier -53 would trigger an automatic review, but because the HCFA fee schedule includes a specific listing for 45378-53 a review is not triggered. 45378 is the only CPT code that has a separate fee schedule listing when modifier -53 is attached. In addition, colonoscopies are subject to HCFAs multiple endoscopy rule, which, when applicable, supersedes multiple procedure guidelines.
Because the combination of guidelines is unique to diagnostic colonoscopies, coders need to familiarize themselves with these procedures and the rules governing their coding and reimbursement to obtain correct payment.
Although colonoscopies usually are associated with gastroenterologists, many general surgeons also perform the procedure, particularly in rural areas of the country where a gastroenterologist may not be available.
Identifying Colonoscopies
Colonoscopy is the visualization and examination of the entire colon and the recto-sigmoid. This examination is performed either with a flexible fiberoptic colonoscopy or, more commonly, with an electronic video colonoscopy. To qualify as a colonoscopy, the scope has to move beyond the splenic flexure in the colon. If the scope is used to examine only the sigmoid colon and a portion of the descending colon, it is referred to as a sigmoidoscopy.
Tissue sampling and polyp removal also are commonly performed during a colonoscopy. At times, multiple samplings and interventions (e.g., control of bleeding) are performed in a single colonoscopy procedure.
The diagnostic colonoscopy is one of seven colonoscopies listed in CPT 2000 performed via anal approach. The seven procedures are:
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)
45379 with removal of foreign body
45380 with biopsy, single or multiple
45382 with control of bleeding, any method
45383 with ablation of tumor(s), polyp(s), or
other lesion(s) not amenable to removal by hot biopsy
forceps, bipolar cautery or snare technique
45384 with removal of tumor(s), polyp(s), or
other lesion(s) by hot biopsy forceps or bipolar cautery
45385 with removal of tumor(s), polyp(s), or
other lesion(s) by snare technique
These codes vary not by how far the scope [...]
