General Surgery Coding Alert

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 was placed beyond the splenic flexure, but by what was performed.

Coding an Incomplete Colonoscopy

Sometimes the surgeon wants to perform a colonoscopy but is unable to get the scope beyond the splenic flexure, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C.

For example, Dunaway says, A surgeon can be about 25 to 30 centimeters into the colon, when the scope gets to a turn that the surgeon just cant get past. The surgeon uses abdominal pressure to try to move the scope forward, but after 30 minutes or so, may decide to give up and order a barium enema to view the rest of the colon.

In this scenario, a sigmoidoscopy has been performed because the scope was able to view the sigmoid colon. A sigmoidoscopy (45330, sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) should not be billed. Instead, coders should bill a diagnostic colonoscopy, 45378, with modifier -53 attached. This is outlined in section 15100B of the Medicare Carriers Manual (MCM), which followed the introduction of modifier -53 on Jan. 1, 1997. Medicare also includes a separate fee schedule line item for 45378-53, consistent with the MCM guidelines, which state:

An incomplete colonoscopy (e.g., the inability to extend beyond the splenic flexure) is billed and paid using colonoscopy code 45378 with modifier -53. The Medicare physician fee schedule database has specific values for code 45378-53. These values are the same as for code 45330, sigmoidoscopy, as failure to extend beyond the splenic flexure means that a sigmoidoscopy rather than a colonoscopy has been performed. But, code 45378-53 should be used when an incomplete colonoscopy has been done because other Medicare physician fee schedule database indicators are different for 45378 and 45330.

Note: One difference between indicators for 45378-53 and 45330 is that 45378-53 allows reimbursement for surgical trays (A4550) whereas 45330 does not. Allowing the tray to be billed, in turn, reflects the fact that the surgeon usually prepares for a colonoscopy, such as 45378, more extensively than for a sigmoidoscopy.

CPTs Recommendations Clash With HCFA

Despite HCFAs specific references to 45378 in the MCM, CPT still instructs surgeons to use modifier -52 (reduced services) when the colonoscope does not pass the splenic flexure. According to CPT: For an incomplete colonoscopy, with full preparation for a colonoscopy, use a colonoscopy code with the modifier
-52 and provide documentation.

But general surgery coders would be wise to follow HCFAs lead in this situation rather than CPTs, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill. Medicare is the payer, and it wants to see modifier -53, Mueller says, noting that the inability to move the scope beyond the splenic flexure also is more appropriately described as discontinued, rather than reduced. In this case, the HCFA guidelines should be followed.

Note: Private carriers vary on payment of incomplete colonoscopies. Check with your local carrier to find out whether it requires modifier -53.

Although both HCFA and CPT agree that the procedure is correctly described as a colonoscopy as soon as the scope passes the splenic flexure, there are occasions when the surgeon simply runs out of scope before viewing the entire colon.

For example, a surgeon performs a colonoscopy on a large patient with blood in the stool. The scope gets around the splenic flexure into the transverse colon, but at that point the surgeon runs out of scope and is unable to adequately view the right colon.

The scope also may not be able to advance past the transverse colon or hepatic flexure, or anywhere beyond the splenic flexure, due to a stricture or tortuosity of the bowel, Mueller says.

In such cases, modifier -52 appropriately describes that part of the service was not performed, Mueller says. This is where modifier -52 comes into play. If the surgeon gets past the splenic flexure but doesnt make it all the way to the cecum, it would be correct to code the procedure with modifier -52.

Note: Inexplicably, some Medicare carriers, such as Palmetto Government Benefit Administrators, the Medicare carrier in South Carolina, request modifier -53 be attached to colonoscopies that do not reach the cecum, even though this is contrary to the guidelines in the MCM, which clearly states modifier -53 should be used only if the scope cannot go past the splenic flexure. It is likely that modifier -53 has been used in error because given the fact that 43578-53 has its own line in the fee schedule, the practical result is that if a colonoscopy that reaches the ascending colon is billed using modifier -53, it will be paid the same amount as a sigmoidoscopy.

Follow the Multiple Endoscopy Rule

Sometimes a patient requires more than one colonoscopy procedure. In an example cited in the MCM, a general surgeon, while performing a diagnostic colonoscopy (45378), also takes a biopsy (45380) and removes a polyp by snare technique (45385).

The latter two procedures are payable as long as separate procedures are performed at different sites on the colon. The different site does not have to be in another section of the large bowel; even a separation of 1 centimeters constitutes a separate site.

Note: Endoscopies of the ileum (the section of the small bowel that links to the colon) that are performed from below are also considered colonoscopies.

Because the biopsy and polyp removal are from the same endoscopic family, normal multiple procedures rules do not apply. Instead, billing for these procedures is guided by Medicares multiple endoscopy rule, which states: For multiple endoscopic procedures, use the full value of the highest valued endoscopy plus the difference between the next highest and the base endoscopy.

In the case of the multiple colonoscopies described above, this means that the 45385 would be listed first, followed by 45380. The diagnostic colonoscopy, 45378, is not listed because it is bundled to both of the other procedures (the edit includes a 0 indicator, which means no override is possible).

But 45378 plays a key role in calculating the correct billing amount because it is considered the base code. The calculation is performed as follows: The highest paying procedure is 45385 with 12.62 relative value units (RVUs). This amount is added to the difference between the next highest procedure, 45380, and the base code, 45378 (10.48 - 9.95 = 0.53). The total value of the colonoscopies is 13.15 RVUs (12.62 + 0.53).

Code Separate Site and Procedure With Modifier -59

Although 45380 and 45385 are not bundled, modifier -59 (distinct procedural service) should be appended to the lesser procedure (45380) to indicate that the procedures were performed on different sites.

Note: Modifier -51 (multiple procedures) should never be attached to any multiple colonoscopy procedure, as it may result in a further fee reduction.

Similarly, if the surgeon removes a polyp by snare (45385) and another polyp at a different site by hot biopsy (45384), both procedures are billable. But, as the lesser valued procedure, 45384 would be listed second with modifier -59 attached, and payment would be made on 45384 minus the amount of base code 45378.

If these procedures are performed on the same polyp, however, only one code may be used. For example, if the surgeon fails to remove a single polyp by snare, a hot biopsy removal may be attempted. In this situation, only the successful procedure (i.e., the hot biopsy, 45384) may be billed.

Similarly, when the surgeon removes two polyps by the same technique (e.g., snare) at separate sites, 45385 may be billed only once because the code descriptor for 45385 (as well as 45383 and 45384) specifically states polyp(s).

If multiple polyps are removed by one technique and the time has been well documented (i.e., how much extra time it took to remove the extra polyps compared to the normal time for colonoscopy and polypectomy), some carriers will increase reimburse if 50 percent or more time than usual was spent on the procedure. Modifier -22 (unusual procedural services) should be appended to the appropriate CPT code.