Wiki Changes to colonoscopy coding for 2015

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Colliemom

Colliemom

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Yesterday we listened to a webinar, and the speaker gave us some information and I wanted to see if any of you have heard this...

Up until December 31st, if a patient was having a screening colonoscopy and the physician found something to biopsy, such as a polyp, we would bill the procedure the following way:

45380 -PT or -33, and V76.51, 211.3

When we billed this way the patient would not be billed or have a deductible applied. (because federal guidelines prohibited insurance carriers from applying a deductible to a screening turned diagnostic colonoscopy.)

During the webinar the speaker informed us that for 2015 that rule no longer applies, and if a patient comes in for a screening colonoscopy, and it becomes diagnostic/therapeutic, then the insurance carriers may apply a deductible/coinsurance. Is this correct, have you heard this?

Also, she said that they changed the description for a complete colonoscopy. It always stated to be complete the scope had to be advanced beyond the splenic flexure. She said it now states the scope has to reach the cecum to be considered a complete procedure. (which actually makes sense to me.) Is this correct?
 
The way I understood it was deductible could still be waived, but coinsurance could not.
Also, in 2015 a colonoscopy must reach cecum to be considered complete according to 2015 CPT book.
 
The PT and 33 will still be put on these charges. The misunderstanding we have is that we were told if the colon starts off as screening and we find a polyp use PT and if the colon starts off as screening and we don't find anything then use 33. This is for Medicare and Medicare products. Hopefully the speaker will follow up by email to help me with this.
 
Modifier Clarification

Hi -
Just to clarify. PT modifier is used for Medicare only. 33 is for commercial payers only, including Medicare Advantage. The PT and 33 tell the payer the same information - you initially planned on performing a screening colonoscopy (routine or high risk) and the procedure turned diagnostic by removing polyps, ablating lesions or performing random biopsies due to the findings during the procedure.

On a side note, there's an issue with Medicare's new HCPCS G6024 in 2015 (this code replaces the new CPT 45388 which replaced deleted code 45383 - colonoscopy w/ablation). Currently, if you append modifier PT to G6024, Medicare denies the claim for invalid use of modifier (seems to be an oversight on their part with updating the modifier code edits to include their new G codes this year). CMS has been notified.

- Elaine
 
45380 PT and 46930 59 was billed, MCR denied the 45380 because the procedure/modifier in combination was not compatible, diagnosis was the screening V76.51. :confused:
 
I too am confused. Have billed for a Colorectal surgeon for many years and I find conflicting information on everything.

I was taught that if it was a Screening Colonoscopy and a Polyp was found that you use the V76.51 as primary and your Polyp as a 2ndary diagnosis. But I read in the AGA as well as CMS guidelines and it states that if a polyp was removed that you do add both diagnosis on the claim form but in Item 24E (Diagnosis Pointer) you only mark your 2nd diagnosis to show the Polyp. Then you modify your appropriate procedure code with the correct modifier (PT or 33). That shows that the pt came in for the Screening, but a Polyp was found and removed.

I can not seem to get a clear answer on that even though I've looked it up on those 2 websites. I have insurance companies calling me asking me to mark the Diagnosis Pointer area with both diagnosis. Anyone else having this problem?
 
@daryleslie

Can you please send me a link as to where you found these guidelines via CMS.
I agree with you completely. I just really need something in writing :)

We are getting denials when using the -PT or -33 when screening turns therapeutic and we can't figure out why.

We are beginning to think some commercial payers accept the -33 and some do not. We are watching for trends.
 
jthomas,CMC

The new 2016 guidelines state if a patient is scheduled for a screening colonoscopy and a therapeutic procedure is performed but the cecum is not reached to apply the -52 modifier. I have a few cases where the dr removes a polyp and scopes beyond the splenic flexure but does not reach the cecum and aborts the procedure due to inadequate prep. He then repreps them and brings them back to complete the procedure. Would I then use the -53 modifier rather than the -52, so the 2nd (completed) procedure will be paid as well?
 
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