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.” 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.
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 V76.51 (special screening for malignant neoplasms of colon), V16.0 (family history of malignant neoplasm of gastrointestinal tract), and V12.72 (personal history of colonic polyps).
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
·V76.51, special screening for malignant neoplasms 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
Colorectal cancer screening; colonoscopy on individual at high risk
Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk
Common colorectal screening diagnosis codes
Special screening for malignant neoplasms of colon
Family history of malignant neoplasm of gastrointestinal tract
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.”
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.
To report screening colonoscopy on a patient not considered high risk for colorectal cancer, use HCPCS code G0121 and diagnosis code V76.51 (special 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.
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
·V76.51, Special screening for malignant neoplasms
·555.2, Regional enteritis of small intestine with large intestine
Common ICD-9 diagnosis codes indicating high risk
Personal history of malignant neoplasm of large intestine
Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
Family history of malignant neoplasm of gastrointestinal tract
Personal history of colonic polyps
Regional enteritis of small intestine
Regional enteritis of large intestine
Regional enteritis of small intestine with large intestine
Regional enteritis of unspecified site
Ulcerative (chronic) enterocolitis
Ulcerative (chronic) ileocolitis
Ulcerative (chronic) proctitis
Ulcerative (chronic) proctosigmoiditis
Other ulcerative colitis
Ulcerative colitis, unspecified (non specific PDX on the MCE)
Toxic gastroenteritis and colitis
Other and unspecified non-infectious gastroenteritis and colitis
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
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)
with removal of foreign body
with biopsy, single or multiple
with directed submucosal injection(s), any substance
with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
with removal of tumor(s), polyp(s), or other lesions by snare technique
ØFor small intestine and stomal endoscopy, see 44360-44393
with dilation by balloon, 1 or more strictures
ØDo not report 45386 in conjunction with 45387
with transendoscopic stent placement (includes predilation)
with endoscopic ultrasound examination
ØDo not report 45391 in conjunction with 45330, 45341, 45342, 45378, 76872
with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
ØDo not report 45392 in conjunction with 45330, 45341, 45342, 45378, 76872
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.
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.
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)
·V76.51, Special screening for malignant neoplasms 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.
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
·V76.51, Special screening for malignant neoplasms of colon
·211.3Benign neoplasm of the colon
In this case, reportV76.51 as the primary diagnosis to indicate it was scheduled as a screening test and 211.3 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.
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Dec 11th, 2018 - rdinaso
Some payers also follow Medicare and use G0105/G0121, for instance BCBS does. Who has the time to find out if all other commercial carriers pay on the HCPCS codes as well. Since it's almost 2019, can we assume all other carriers recognize the HCPCS codes too?
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