Primary Care Coding Alert

Family practice coders charged with assigning codes for endoscopic examinations of the lower gastrointestinal tract may find their heads spinning because a quick look at CPT 2000 shows that they have more than 25 diagnostic and therapeutic codes from which to choose.

Since nearly half of family physicians report they perform at least one of three types of endoscopic procedures in their offices, a coder likely will be asked to correctly code these services at one time or another. According to a survey conducted by the American Academy of Family Physicians (AAFP), 45 percent of the physicians surveyed said they perform flexible sigmoidoscopies (45330-45339), 15 percent perform rigid sigmoidoscopies or proctosigmoidoscopies (45300-45321), and an additional 4 percent perform colonoscopies (45355-45385).

The key to determining which set of codes to apply lies in understanding the differences between the procedures. Coders must identify the specific diagnostic or therapeutic services provided to establish which code within the set to assign.

Uncovering the Differences Between Gastrointestinal Endoscopic Exams

According to Kent Moore, manager of health care financing and delivery systems for AAFP, coders should begin with a basic understanding of how an endoscopic examination is conducted. During this type of procedure, the family physician will insert a tube into the body to permit visualization of the GI (gastrointestinal) tract. Although it is often used as a diagnostic tool, the doctor also may use this technique to provide other services, like specimen collection, biopsies or removal of a growth.

Proctosigmoidoscopy, also called rigid sigmoidoscopy, is performed to examine the most distal portions of the GI tract, the rectum and sigmoid colon. It may be conducted as a diagnostic measure when patients exhibit symptoms indicating hemorrhage of rectum and anus (569.3), anal or rectal polyp (569.0), or anal or rectal pain (569.42), among others.

Flexible sigmoidoscopy is performed with a fiberoptic scope that can be used not only to view the colon, but also to take biopsies of the mucosa. The length of the scope allows the physician to examine portions of the gastrointestinal tract not visible with the rigid scope. Specifically, this exam allows the physician to visualize the entire rectum, sigmoid colon, the descending colon and some parts of the transverse colon.

It is not uncommon for a family physician to conduct this in his or her office, Moore says. It is used as a diagnostic study when a patient presents with a variety of GI-related complaints.

Diagnostic codes frequently associated with flexible sigmoidoscopy include 153.0-153.9 (malignant neoplasm of colon), 280.9 (iron deficiency anemia, unspecified), 455.2 (internal hemorrhoids with other complication), 560.0-560.89 (intestinal obstruction without mention of hernia), 562.10-562.13 (diverticula of colon), 564.0-564.1 (constipation, irritable colon), and 936 (foreign body in intestine and colon).

In addition, many physicians use this procedure as a screening test for colon cancer, and some payers allow several V-codes to be assigned for sigmoidoscopies. These include V10.05 (personal history of malignant neoplasm of large intestine), V10.06 (personal history of malignant neoplasm rectum, rectosigmoid junction, and anus) and V12.72 (personal history of colonic polyps). In addition, coders should note that these V-codes are not considered primary diagnosis codes and should be used only in conjunction with another diagnosis code on the claim. Before assigning these codes, however, be sure to check with the carrier in question to determine if V-codes are billable.

Colonoscopies are performed with a larger and longer scope that can reach the entire colon. They may be conducted in a family practice setting, Moore says, although most family physicians refer patients to a gastroenterologist or general surgeon when this exam is necessary. Colonoscopies can become quite complex and may require conscious sedation, which adds another level of service and coding.

Colonoscopies include examination of the entire colon from rectum to cecum (the segment below the terminal ileum that forms the first section of the large intestine) and may advance into the ileum itself. In addition to some of the codes that may be assigned to sigmoidoscopies, diagnoses associated with colonoscopies include 230.3 (carcinoma in situ, colon), 789.00-789.09 (abdominal pain) and 555.0-555.9 (regional enteritis). In addition, some carriers also allow a series of V-codes for colonoscopies, which indicate personal or family history of related conditions, to be assigned.

Begin With a Diagnostic Code

Each of the three endoscopic series begins with a basic diagnostic code, Moore explains. Once coders have determined which of the three procedures was conducted, they can begin there.

For instance, code 45330 (sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) would be assigned for a diagnostic sigmoidoscopy exam. Similarly, 45300 (proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) would be assigned for a diagnostic proctosigmoidoscopy and 45378 for a diagnostic colonoscopy.

Once the physician has conducted the diagnostic exam, however, he or she may perform other services. Perhaps a foreign body was removed, a biopsy was done, or a polyp removed. Each of these scenarios is reflected in the series of codes for each endoscopic exam. If a biopsy was done during a sigmoidoscopy, for instance, coders would assign 45331 (sigmoidoscopy, flexible; with biopsy, single or multiple). Removal of a foreign object would be coded 45332 (sigmoidoscopy, flexible; with removal of foreign body).

If a polyp was removed during the sigmoidoscopy, coders would need to determine the technique used, which should be documented clearly in the patient record. For instance, removal of tumors, polyps, or other lesions by hot biopsy forceps or bipolar cautery would be coded 45333 (sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery), while removal by snare technique would be coded 45338 (sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Although there are a lot of codes in each series, they are fairly straightforward, says Moore. A description of what was done should be stated in the medical record and that will lead to the correct code.

If the family physician performed additional services following the diagnostic exam, coders should remember to report only the therapeutic code. You cant code both the diagnostic code and the surgical code, cautions Moore.

How to Report Endoscopic Screening

As with many other screening exams (i.e., mamm-ography, prostate specific antigens [PSAs]), the Health Care Financing Administration (HCFA) has established special endoscopy codes for Medicare beneficiaries undergoing screening for colorectal cancer.

Coders need to be aware of these HCPCS codes and understand when to use them, says Deepa Malhotra, MS, CPC, coding and compliance manager for Healthcare Information Services, Ltd., in Willowbrook, Ill., which provides billing services to more than 200 physicians throughout the Chicago metropolitan area. In this instance, the endoscopy codes are G-codes and need to be reported when the family physician conducts an endoscopic exam to screen for gastrointestinal cancers. Each of the codes carries specific frequency and eligibility requirements that need to be considered, she adds.

The code most family practice coders will use is G0104 (colorectal cancer screening; flexible sigmoidoscopy). This exam may be performed on patients 50 years and older and repeated every four years. Medicare will not cover the procedure unless at least 47 months have elapsed since the previous screening.

G0105 (colorectal cancer screening; colonoscopy on individual at high risk) is used infrequently by family physicians. It is likely that a family physician would refer a patient to another specialist if he or she felt that patient was at high risk for cancer and required a screening colonoscopy, Moore says.

These exams may be done on patients of any age, he notes, but they must exhibit one or more of the following high-risk characteristics:

A close relative (sibling, parent or child) who has
had colorectal cancer or adenomatous polyposis;
A family history of adenomatous polyposis;
A family history of hereditary nonpolyposis
colorectal cancer;
A personal history of adenomatous polyps;
A personal history of colorectal cancer; and/or
Inflammatory bowel disease, including Crohns
disease and ulcerative colitis.

Colonoscopies May Require Conscious Sedation

Although infrequent, screening, diagnostic or therapeutic colonoscopies may be performed in family practice settings. When they are done, conscious sedation is virtually always administered. In these cases, coding professionals must be aware of how to code this additional level of service.

CPT provides two codes that may be used:

99141 sedation with or without analgesia
(conscious sedation); intravenous,
intramuscular or inhalation, or

99142 sedation with or without analgesia
(conscious sedation); oral, rectal and/or intranasal.

When assigning 99141 and 99142, coders must be aware that the presence of an independent trained observer to assist the physician in monitoring the patients level of consciousness and their physiological status is required during the procedure. The observer must be in attendance throughout the exam, and this must be stated clearly in the report.

In addition, the observer must be a professional with medical training that qualifies him or her to monitor the medical condition of the patient. This may be another physician, a physician assistant, a nurse practitioner, a registered nurse or a medical student.

Moore cautions, however, that Medicare does not pay separately for conscious sedation. The two codes noted above have a B status in the Medicare Fee Schedule. This means that they are bundled with other covered services and not paid separately, he concludes.