Coding for Screening Colonoscopies

How to code for screening colonoscopies, what modifiers are needed and what diagnosis codes to assign can be challenging for surgeons. An area of particular confusion is screening colonoscopies converted to a diagnostic or therapeutic colonoscopy.  To complicate the issue, Medicare uses different procedure codes than other payers. This article will help surgeons and their office staffs decide the procedure and diagnosis codes used to report colonoscopy services.

What is the difference between a screening and a diagnostic colonoscopy?

A screening test is a test provided to a patient in the absence of signs or symptoms based on the patient’s age, gender, medical history and family history according to medical guidelines.   It is defined by the population on which the test is performed, not the results or findings of the test. As such, “screening” describes a colonoscopy that is routinely performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps.  Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.” [1]As part of the Affordable Care Act (ACA), Medicare and most third-party payers are required to cover services given an A or B rating by the U.S. Preventive Services Task Force (USPSTF) without a co-pay or deductible.  That is, the patient has no patient due amount.  However, diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign or symptom.  Medicare does not waive the co-pay and deductible when the intent of the visit is to perform a diagnostic colonoscopy.

Confounding this issue is a surveillance colonoscopy—one performed at more frequent intervals than every ten years because the patient has a personal history of colonic polyps.  Should this be billed as screening (in the absence of current signs/symptoms) or diagnostic, because it is being performed because of the personal history of the patient?  Neither CPT nor CMS address this directly, but I will give my recommendations below, in Clinical Scenario five, at the end of this article.

There are two sets of procedure codes used for screening colonoscopy:  CPT code 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) and Healthcare Common Procedural Coding System (HCPCS) codes G0105 (colorectal cancer screening; colonoscopy on individual at high risk) and G0121 (colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk).   Why two sets of codes?  The Centers for Medicare and Medicaid Services (CMS) developed the HCPCS codes to differentiate between screening and diagnostic colonoscopies in the Medicare population.

Common diagnosis codes for colorectal cancer screening include Z12.11 (encounter for screening for malignant neoplasm of colon), Z80.0 (family history of malignant neoplasm of digestive organs), and Z86.010 (personal history of colonic polyps).

 Clinical scenario one

A 70-year-old Medicare patient calls the surgeon’s office and requests a screening colonoscopy.  The patient’s previous colonoscopy was at 59-years old, and was normal.  The patient has no history of polyps or colorectal cancer and none of the patient’s siblings, parents or children has a history of polyps or colorectal cancer.  The patient is eligible for a screening colonoscopy.  Reportable procedure and diagnoses include:

  • G0121, colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk
  • 11, encounter for screening for malignant neoplasm of colon

The HCPCS code is the correct code to use—not the CPT code—because the patient is a Medicare patient.  Additionally, G0121 is selected because the patient is not identified as high risk.

HCPCS and CPT screening colonoscopy codes

HCPCS/CPT   code

Description

45378

Colonoscopy

G0105

Colorectal cancer screening; colonoscopy on individual at high risk

G1021

Colorectal cancer screening; colonoscopy on individual not meeting the   criteria for high risk

 

Common colorectal screening diagnosis codes

ICD-10-CM

Description

Z12.11

Encounter for screening for malignant neoplasm of colon

Z80.0

Family history of malignant neoplasm of digestive organs

Z86.010

Personal history of colonic polyps

 

E/M service prior to a screening colonoscopy

Typically, procedure codes with 0, 10 or 90-day global periods include pre-work, intraoperative work, and post-operative work in the Relative Value Units (RVUs) assigned.  As a result, CMS’ policy does not allow for payment of an Evaluation and Management (E/M) service prior to a screening colonoscopy.   In 2005, the Medicare carrier in Rhode Island explained the policy this way:

Medicare does not cover an E/M prior to a screening colonoscopy. An item or service must have a defined benefit category in the law to be covered under Medicare. For example, physicians services are covered under section 1861(s)(1) of the Social Security Act. However, section 1862(a)(1)(A) states that no payment may be made for items or services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. In addition, section 1862(a)(7) prohibits payment for routine physical checkups. These sections prohibit payment for routine screening services, those services furnished in the absence of signs, symptoms, complaints, or personal history of disease or injury. … While the law specifically provides for a screening colonoscopy, it does not also specifically provide for a separate screening visit prior to the procedure. The Office of General Counsel (OGC) was consulted to determine if sections 1861(s)(2)(R) and 1861(pp) could be interpreted to allow separate payment for a pre- procedure screening visit in addition to the screening colonoscopy. The OGC advises that the statute does not provide for such a preprocedure screening visit.”  [2]

Medicare defines an E/M prior to a screening colonoscopy as routine, and thus non-covered.  However, when the intent of the visit is a diagnostic colonoscopy an E/M prior to the procedure ordered for a finding, sign or symptom is a covered service.

Third-party payers that do not follow Medicare guidelines may reimburse a surgeon for an E/M service prior to a screening colonoscopy.  However, these visits are typically documented in a way that the level of E/M service is low.  A new patient or consult reported as a level three or higher requires four elements of the history of the present illness (HPI).  The HPI elements are location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.  For a patient who presents with no complaints for screening, the HPI does not typically have four of these elements.

Screening colonoscopy for Medicare patients

Report a screening colonoscopy for a Medicare patient using G0105 (colorectal cancer screening; colonoscopy on individual at high risk) and G0121 (colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk).

Medicare beneficiaries without high risk factors are eligible for screening colonoscopy every ten years. Beneficiaries at high risk for developing colorectal cancer are eligible once every 24 months.  Medicare considers an individual at high risk for developing colorectal cancer as one who has one or more of the following:

  • A close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp.
  • A family history of familial adenomatous polyposis.
  • A family history of hereditary nonpolyposis colorectal cancer.
  • A personal history of adenomatous polyps.
  • A personal history of colorectal cancer.
  • Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis.[3]

To report screening colonoscopy on a patient not considered high risk for colorectal cancer, use HCPCS code G0121 and diagnosis code Z12.11 (encounter for screening for malignant neoplasm of the colon).   To report screening on a Medicare beneficiary at high risk for colorectal cancer, use HCPCS G0105 and the appropriate diagnosis code that necessitates the more frequent screening.

Clinical scenario two

A Medicare patient with a history of Crohn’s disease presents for a screening colonoscopy.  Her most recent screening colonoscopy was 25 months ago.  No abnormalities are found. Reportable procedures and diagnoses include:

  • G0105, Colorectal cancer screening; colonoscopy on individual at high risk
  • 11, Encounter for screening for malignant neoplasm of colon
  • 80, Crohn’s disease of both small and large intestine without complications
 

Common ICD-10 diagnosis codes indicating high risk

Z85.038

Personal history of other malignant neoplasm of large intestine

Z85.048

Personal history of other malignant neoplasm of rectum, rectosigmoid   junction, and anus

Z80.0

Family history of malignant neoplasm of digestive organs

Z86.010

Personal history of colonic polyps

Screening colonoscopy for Medicare patients that becomes diagnostic or therapeutic

It is not uncommon to remove one or more polyps at the time of a screening colonoscopy.  Because the procedure was initiated as a screening the screening diagnosis is primary and the polyp(s) is secondary. Additionally, the surgeon does not report the screening colonoscopy code, but reports the appropriate code for the diagnostic or therapeutic procedure performed, CPT code 45379—45392.

Colonoscopy CPT codes

CPT Code

Descriptor

ž 45378

Colonoscopy; flexible, diagnostic, including collection of specimen (s) by brushing or washing, when performed(separate procedure)

ž 45379

with removal of foreign body (s)

ž 45380

with biopsy, single or multiple

ž 45381

with directed submucosal injection(s),   any substance

ž 45382

with control of bleeding, any method

ž 45383

with ablation of tumor(s), polyp(s),  or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)

ž 45384

with removal of tumor(s), polyp(s), or  other lesion(s) by hot biopsy forceps

ž 45385

with removal of tumor(s), polyp(s), or   other lesions by snare technique

ž 45386

with transendoscopic balloon dilation

ž 45389

with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed)

ž 45390

Colonoscopy, flexible; with endoscopic mucosal resection

ž 45391

with transendoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures

ž 45392

with transendoscopic ultrasound guided   intramural or transmural fine needle aspiration/biopsy(s) includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse or ascending colon and cecum, and adjacent structures

ž 45393

Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed

ž 45398

Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids)

CMS developed the PT modifier to indicate that a colonoscopy that was scheduled as a screening was converted to a diagnostic or therapeutic procedure.  The PT modifier (colorectal cancer screening test, converted to diagnostic test or other procedure) is appended to the CPT code. Add modifier PT to the CPT codes above to indicate that a scheduled screening colonoscopy was converted to diagnostic or therapeutic.  Modifier PT should be added to the anesthesia service as well.  This informs Medicare that it was a service performed for screening and the patient will not be charged a copay or deductible.

Screening colonoscopy for non-Medicare patients

When reporting a screening colonoscopy on a non-Medicare patient, report CPT code 45378 and use the appropriate screening diagnosis code.  As a result of the ACA, Patients covered by a group insurance policy that was purchased or renewed after September 2010 will have no co-pay or deductible, unless the plan applied for grandfathered status.

Clinical scenario three

A 52-year-old patient calls the surgeon’s office and requests a screening colonoscopy.  The patient has never had a screening colonoscopy. The patient has no history of polyps and none of the patient’s siblings, parents or children has a history of polyps or colon cancer.  The patient is eligible for a screening colonoscopy.  Reportable procedure and diagnoses include:

  • 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)
  • 11, Encounter for screening for malignant neoplasm of colon

Screening colonoscopy for non-Medicare patients that becomes diagnostic or therapeutic

When a screening colonoscopy converts to a diagnostic or therapeutic procedure for a non-Medicare patient, the surgeon must document that the intent of the procedure was screening in order for the patient’s insurance to process the claim without out-of-pocket expense in accordance with the ACA.  CPT developed the 33 modifier for preventive services,  “when the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure.” For example, if a surgeon performing a screening colonoscopy finds and removes a polyp with a snare, use CPT code 45385 and append modifier 33 to the CPT code.

Clinical scenario four

The same 52- year-old patient from the previous example has had an abnormal finding during their screening colonoscopy. The surgeon removes a polyp with a snare technique. Reportable procedure and diagnoses include:

  • 45385-33, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesions by snare technique
  • 11, Encounter for screening for malignant neoplass of colon
  • 5 Polyp of the colon

In this case, report Z12.11 as the primary diagnosis to indicate it was scheduled as a screening test and K63.5 as the secondary diagnosis.  In addition, modifier 33 tells the payer that the primary purpose of the test was screening, in accordance with evidence based practice as identified by USPSTF.

Diagnosis code ordering is important for a screening procedure turned diagnostic

When the intent of a visit is screening, and findings result in a diagnostic or therapeutic service, the ordering of the diagnosis codes can affect how payers process the claim.  There is considerable variation in how payers process claims, and the order of the diagnosis code may affect whether the patient has out–of-pocket expense for the procedure.  The appropriate screening diagnosis code should be placed in the first position of the claim form and the finding or condition diagnosis in the second position.  It is important to verify a payer’s reporting preference to avoid payment denials.

There are two sets of procedure codes that describe colonoscopy services. Additionally, there are different preventative service modifiers for Medicare and other third-party payers.  The order of diagnosis coding can affect how a payer processes the claim and whether there is an out-of-pocket expense for the patient.  Mastering the coding for each payer may result in lower claims processing costs, quicker payments, and fewer patient complaints.

Clinical scenario five

At a routine screening, a patient is found to have an adenomatous polyp.  The surgeon recommends that the patient return for a surveillance colonoscopy in three years. (The USPSTF recommendations do not address frequency of this repeat surveillance.  The American Cancer Society does have recommendations. [1])  Is this test diagnostic or screening?  How it is coded will determine the patient due amount.  The definition of modifier 33 is specific, and so many groups will not apply the modifier for surveillance colonoscopies. (Modifier 33–Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure.  When reporting the diagnosis code, I would suggest reporting Z12.11 (encounter for screening for malignant neoplasm of the digestive organs) and Z86.010 (personal history of colonic polyps) second.  The patient will probably need to appeal this to their insurance company.

 

All specific references to CPT (Current Procedural Terminology) codes and descriptions are © 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

†Current Procedural Terminology (CPT). Copyright 2016 American medical Association. All Rights Reserved.

[1] “Coverage of Colonoscopies Under the Affordable Care Act’s Prevention Benefit,” September 2012  The Henry Kaiser Family Foundation

[2] Evaluation & Management Visit Prior to a Colonoscopy  Medicare Part B Bulletin BCBS of AR: Feb 1, 2005

[3] http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html, Publication 100-04, Chapter 18, Section 60.3


 

[1] http://www.cancer.org/cancer/colonandrectumcancer/moreinformation/colonandrectumcancerearlydetection/colorectal-cancer-early-detection-acs-recommendations

FOR MORE CODING RESOURCES VISIT WWW.CODINGINTEL.COM

3 thoughts on “Coding for Screening Colonoscopies

  1. I agree with your statement re: covering a screening colonoscopy– “whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.” But, physicians and coders are (incorrectly) coding a screening procedure as diagnostic when something–anything, including non-cancer items such as hemorrhoids and diverticulitis, are detected. We have the technology to prevent colon cancer, but shifting the financial burden away from facilities and insurance providers onto consumers has resulted in a significant obstacle (as if consumers weren’t already hesitant). Despite the intent of federal legislation and some state laws intending to ensure coverage, coders persist in this policy. I called 5 of the larger facilities in our area who perform colonoscopies and asked, “For my first colonoscopy, being asymptomatic with no personal history, over the age of 50, if something is found, how would you code it?” All 5 said it would be coded as diagnostic. In our state, that would be a bill close to $3000.

    I meet with one of our state’s representative and someone from the insurance commissioner’s office, American Cancer Society and others, to discuss how, in Oregon, which has a law to protect consumers, we can ensure the laws are upheld. Appreciate any insights/resources/ideas. Right now the only recourse consumers have when they get billed incorrectly is to file an appeal, which has mixed results.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s