By Mandeara Frye, RHIA, CPC, CPMA, CASCC, Director of Coding
Understanding when a colonoscopy is a screening or diagnostic procedure
is critical not only for accurate code selection but also for the billing
process since patient benefits vary for each service. This month, we’ll
review the common criteria for screenings and how to properly code both
screening and diagnostic colonoscopies.
Screening Criteria
The American Cancer Society
recommends individuals who are at average risk of colorectal cancer start regular
screenings at the age of 45. Average risk means those people who do not
have a personal history of colon cancer, polyps, or inflammatory bowel
disease or a family history of colorectal cancer. Those who have a personal
or family history are considered high risk and may need to begin screening
before age 45, depending on their history.
Medicare covers an average risk screening colonoscopy once every 10 years,
whereas high-risk screenings are covered once every 24 months. If the
colonoscopy results are normal, there is no cost to the patient for this
service. If a polyp or other pathology is found during the encounter and
is treated, then the patient may be responsible for a 20% co-insurance
and/or a co-pay but would not be responsible for the deductible. For patients
with commercial insurance, it’s important to verify screening benefits
since they may have specific coverage requirements concerning age and
frequency.
The codes for screenings include:
Diagnoses
- Z12.11 – Encounter for screening for malignant neoplasm of colon
- Z85.038 – Personal history of other malignant neoplasm of large intestine
- Z86.010 – Personal history of colonic polyps
- Z80.0 – Family history of malignant neoplasm of digestive organs
Medicare Procedure Codes
-
G0121 – Colorectal cancer screening; colonoscopy on
individual
not meeting criteria for high risk
-
G0105 – Colorectal cancer screening; colonoscopy on
individual at high risk
- G0104 – Colorectal cancer screening; flexible sigmoidoscopy
Note: High versus low risk is not a factor for a screening sigmoidoscopy.
Commercial Procedure Codes
- 45378 – Colonoscopy, flexible; diagnostic, including collection of
specimen(s) by brushing or washing, when performed (separate procedure)
- 45330 – Sigmoidoscopy, flexible; diagnostic, including collection
of specimen(s) by brushing or washing, when performed (separate procedure)
If a polyp or other pathology is found and treated, this is considered
a screening-turned-diagnostic procedure and the appropriate CPT code should
be used based on the technique(s) with a modifier PT (colorectal cancer
screening test; converted to diagnostic test or other procedure) added
for Medicare or 33 (preventative services) added for commercial. If multiple
methods of removal are used for separate polyps/lesions, then each method
can be reported separately. For example, if a sigmoid polyp is removed
using hot biopsy forceps and a rectal polyp removed via snare, 45384 and
45385 would be reported. Each technique is only reported once per encounter,
even if multiple polyps/lesions were removed using that technique.
Common Diagnostic/Therapeutic Procedure Codes
- 45380 – Colonoscopy, flexible; with biopsy, single or multiple
- 45381 – Colonoscopy, flexible; with directed submucosal injection(s),
any substance
- 45382 – Colonoscopy, flexible; with control of bleeding, any method
- 45384 – Colonoscopy, flexible; with removal of tumor(s), polyp(s),
or other lesion(s) by hot biopsy forceps
- 45385 – Colonoscopy, flexible; with removal of tumor(s), polyp(s),
or other lesion(s) by snare technique
- 45388 – Colonoscopy, flexible; with ablation of tumor(s), polyp(s),
or other lesion(s) (includes pre- and post-dilation and guide wire passage,
when performed)
- 45390 – Colonoscopy, flexible; with endoscopic mucosal resection
Diagnostic
When a patient presents for a colonoscopy due to a gastrointestinal issue,
then this becomes a diagnostic procedure. Even if the patient qualifies
for a screening, a screening cannot be coded if they have symptoms. The
coder should code the symptoms or applicable findings and any interventions
performed.
Positive Cologuard
Cologuard tests are commonly used as part of the colorectal cancer screening
process as a less-invasive alternative to a colonoscopy. These tests detect
alterations in a patient’s DNA associated with colon cancer and
precancerous polyps. If a patient has a positive Cologuard test, a colonoscopy
is necessary as a next step to survey for these lesions. According to
the American Hospital Association1, the subsequent test(s) following a positive Cologuard test are considered
diagnostic, not screening.
When a patient undergoes colonoscopy for a positive Cologuard test and
there are no abnormal findings, the coder would report the diagnosis as
R19.5 (other fecal abnormalities). Per the official
ICD-10-CM guidelines, “For patients receiving diagnostic services only during an encounter/visit,
sequence first the diagnosis, condition, problem or other reason for encounter/visit
shown in the medical record to be chiefly responsible for the outpatient
services provided during the encounter/visit.”2
If the patient undergoes a colonoscopy for a positive Cologuard and a polyp
is found, the coder would select K63.5 (polyp of colon) as the first-listed
diagnosis for the colonoscopy. The guidelines for outpatient services
state, “For outpatient encounters for diagnostic tests that have
been interpreted by a physician, and the final report is available at
the time of coding, code any confirmed or definitive diagnosis(es) documented
in the interpretation.”
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References:
1. AHA Coding Clinic for HCPCS, Second Quarter 2018, Volume 18, Number 2, Page 4
2. AHA Coding Clinic for ICD, First Quarter 2019, Volume 6, Number 1, Page 32