Screening Colonoscopies

We are trying to get this straight in our billing company also. I was told by our facility that they bill both the G code and the diagnostic code (CPT® codes) to Cigna and BCBS and that is how they are telling them the colon started out as a screening and turned diagnostic. They also add a modifier 59 to one of the CPT® codes. I have never heard of this and it sounds incorrect to me.

I would just like clarification - if a screening colon turns diagnostic, we should bill with the diagnostic CPT® code (45378 for example) and then the V code a primary dx and diagnostic dx as 2nd dx.

Also, do you have any experience using modifier 33 successfully? We have been told by several carriers they do not recognize this modifier.

re: Screening Colonoscopies

I only change screenings to diagnostic if polyps are removed. If this is the case I bill for example 45385 with diag code V76.51 and 211.3 second. If polyps are removed by cold biopsy forceps also I use 45385, 45380-59 with V76.51 followed by 211.3. The same scenario goes for G0105. The G code and the diagnostic code would not be billed together.

re: Screening Colonoscopies

You should append a modifier to any procedure that starts out as screening and turns to diagnostic so that the insurance company knows it started out as screening. Use modifier 33 for commercial insurance companies, and modifier PT for Medicare, Medicare replacement, and Medical Assistance. Insurance companies will (at least in my experience) then cover the procedure like they would a screening procedure and will not apply a deductible/co-pay for the portion they would consider for the colonoscopy itself (they crop out the allowed amount for 45378). They may or may not do the same for the portion that is the polyp removal, biopsy, etc.

re: Screening Colonoscopies

The G codes are only used by Medicare. You cannot bill 45380 and the G code at the same time. If a screening colonoscopy turns into a dx use modifier 33 for all Insurances but Medicare. For Medicare use PT. If it's a Medicare patient with a hx of polyps but at the current session no polyps are removed us the G code for High Risk patient. If it's the first procedure ever and no polyps are removed use the G code for "no risk" patient. Also don't forget to have your Medicare patients sign an ABN in case that it hasn't been 10 years since their last screening colonoscopy.