Primary Care Coding Alert

Family physicians (FPs) perform proctosigmoidoscopies (proctos) and flexible sigmoidoscopies (flex sigs) to examine a patients rectum and distal colon for screening, diagnosis or treatment of a problem. FP coders must know how to bill for these procedures when they are screenings, when theyre performed due to a patient complaint, and when they are discontinued.
 
To perform a proctosigmoidoscopy, the FP inserts a rigid endoscope in the rectum and sigmoid colon. A procto is usually performed because the patient exhibits symptoms such as bleeding (569.3) or rectal pain (569.42). A flex sig is the examination of the entire rectum, sigmoid colon and sometimes a portion of the descending colon with a flexible scope. A flex sig may be performed to identify a problem, but most often it is done as a diagnostic screening to check if the patient has colorectal (colon) cancer. 
 
Coding the Diagnostic Screening
 
 
For correctly billing the flex sig when it is performed as a screening, accurate diagnosis coding is the key. Medicare covers colon cancer screenings via flex sigs once every four years for patients 50 years or older. For Medicare patients, use G0104 (Colorectal cancer screening; flexible sigmoidoscopy) with V76.51 (Special screening for malignant neoplasms; intestine; colon). Use 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and V76.51 to bill a screening flex sig to commercial carriers.
 
As a general rule, screening procedures have limited coverage by commercial insurance companies, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. Its important to know ahead of time if the patients insurance is going to pay so you can tell them if its a noncovered service before the procedure. Family practices should have commercial-insurance patients sign an advance beneficiary notice (ABN) before the procedure.
 
A screening exam is performed in the absence of patient complaints or symptoms. If, during the flex sig screening, the FP finds a problem, coders cannot change the diagnosis code. The initial V76.51 should be used whether or not the FP makes a definitive diagnosis. Its improper to use the physicians final diagnosis when coding for a screening, says Callaway. The diagnosis has to reflect that the patient is there for a screening, whether its paid or not. It cant be changed even if a problem is found.
 
Sometimes a screening can turn into another service. For example, during a screening flex sig the FP sees a polyp and takes a biopsy of it. In this instance, coders should use 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple). Use a corresponding diagnosis code to reflect the polyp (e.g., 211.3, Benign neoplasm of other parts of digestive system; colon), depending on its location. You wouldnt code for the screening exam in this case because the screening becomes bundled into the other service, says Callaway.

 
When a patient presents with signs and symptoms prompting a procto or flex sig, the procedure is not a screening exam. Use 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for proctos, and 45330 for flex sigs that are not screenings. Report the doctors definitive diagnosis, if there is one. You can use either the diagnosis for signs and symptoms or the final diagnosis.  
 
For example, a patient presents with change of bowel habits and bleeding from the rectum. The FP performs a flex sig to determine the problem. The physician finds a small polyp and biopsies it to make sure it is benign. Report 45331 with 211.3.

 
Sometimes, when a problem is found during a screening, the FP has to spend a lot of time counseling the patient after the procedure. Although it is rare that the physician would spend more than five to 10 minutes, a patient may become distraught and have to be counseled for as long as 30 minutes.  
 
If a substantial amount of time is spent way beyond the typical amount of time spent after a procedure discussing the diagnosis, coordinating care and calming the patient, you can code an office visit separately, says Glenn Littenberg, MD, a member of the AMA CPT Editorial Panel and a gastroenterologist in private practice in Pasadena, Calif. You can base the E/M level on time. Bill the appropriate E/M established patient office visit code (99211-99215) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended along with 45330 or G0104.   
 
Coders can also bill an office visit separately from a flex sig when the patient comes in for an office visit and the physician decides to perform the sigmoidoscopy on the same day. For example, a patient visits the FP complain-ing of blood in his or her stool. The FP may decide the problem warrants an immediate flex sig, says Littenberg. The physician performs the sigmoidoscopy, finds a form of colitis, and takes a biopsy. Report the appropriate E/M code with modifier -25 attached and 45331. Link 569.3 (Hemorrhage of rectum and anus) to the E/M code, and link 558.9 (Other and unspecified noninfectious gastroenteritis and colitis) to 45331.
 
Modifiers for Incomplete Procedure

 
An FP intending to perform a flex sig may have to cut the procedure short for various reasons. If you go in with the anticipation that youre performing a higher-valued service, you should get paid for that, says Callaway. For example, the patient may have severe discomfort, and the physician decides to stop the procedure and perform it at a later date. Append modifier -53 (Discontinued procedure) to 45330. Most payers will pay in full when the physician performs the procedure a second time, as long as modifier -76 (Repeat procedure by same physician) is appended. Reimbursement will be at the discretion of the carrier, which will base payment for both procedures on the documentation. The physician should submit a written report for both procedures, making clear what length of colon was examined each time and why the initial procedure was discontinued prematurely.
 
The next time, the FP may use conscious sedation on the patient for procedures that were stopped due to patient discomfort. Reimbursement for conscious sedation during a flex sig depends on the payer. Medicare does not cover it, but some private payers do, so family practices should submit a claim for it with 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation).