Coding FAQ - Screening Colonoscopy
A screening test is a test provided to a patient in the absence of signs or symptoms. A screening colonoscopy is a service 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 payors 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.
Diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign or symptom (such as abdominal pain, bleeding, diarrhea, etc.). Medicare and most payors do not waive the co-pay and deductible when the intent of the visit is to perform a diagnostic colonoscopy.
For commercial and Medicaid patients, use 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]).
For Medicare beneficiaries, use Healthcare Common Procedural Coding System (HCPCS) code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk) as appropriate. 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).
V12.72 (Personal history of colonic polyps).
If a polyp is found, some Medicare contractors require 211.3 (Benign neoplasm, colon) in the first line of the claim.
Medicare beneficiaries without high risk factors are eligible for screening colonoscopy every 10 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.
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. The endoscopist reports the appropriate code for the diagnostic or therapeutic procedure performed, e.g. CPT code 45379—45392.
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.
CPT developed modifier 33 for preventive services, “when the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. 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 physician performing a screening colonoscopy finds and removes a polyp with a snare, use CPT code 45385 and append modifier 33 to the CPT code.
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 payors process the claim. There is considerable variation in how payors process claims, and the order of the diagnosis code may affect whether the patient has out-of-pocket expenses 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 payor’s reporting preference to avoid payment denials.
Here are some examples for screening colonoscopy, which applies to both the physician and outpatient facility. Claims should be coded the same for procedures, modifiers and diagnosis with the exception of the discontinued procedure modifier (when the physician uses modifier 53, the outpatient hospital/ambulatory surgical facility uses modifier 74).
Indication: Colon screening
Post-endoscopy finding: Normal colonic mucosa
Procedure code: G0121 (Average risk screening) or 45378-33 (Diagnostic colonoscopy with modifier 33 indicating this is a preventive service).
Diagnosis code: V76.51 (Special screening for malignant neoplasms, colon)
Indication: Personal history of colon polyps, Colon screening
Post-endoscopy findings: Normal colonoscopy
Procedure code: G0105 (High risk screening) or 45378-33 (Diagnostic colonoscopy with modifier 33 indicating this is a preventive service)
Diagnosis code: V12.72 (Personal history of colon polyps)
Indication: Colon screening
Post-endoscopy findings: Polyps in the cecum and sigmoid colon
Procedure: Colonoscopy with removal of cecal and sigmoid polyps by snare technique
Procedure code: 45385 (Colonoscopy with removal of polyp by snare)
Modifier PT (if Medicare patient) or Modifier 33 (if non-Medicare) should be added to indicate this was a preventive service and to trigger benefits
Diagnosis code: V76.51 (Special screening for malignant neoplasms, colon). Some Medicare payors instruct to only use the finding since the PT modifier indicates it was done for screening.
211.3 (Benign neoplasm, colon [based on pathology report])
Indication: Personal history of colon polyps; Colon screening
Post-endoscopy findings: Large sessile polyp in the rectum, unable to resect, pending pathology
Procedure: Colonoscopy with biopsy of rectal polyp. Will await pathology and consider surgical referral.
Procedure code: 45380 (Colonoscopy with biopsy)
Modifier PT (if Medicare) or Modifier 33 (non-Medicare) should be added to indicate this was a preventive service and to trigger preventive
Diagnosis code: V12.72 (Personal history of colon polyps). Some Medicare payors [First Coast and Noridian] instruct to only use the finding since the PT modifier indicates it was done for screening.
211.4 (Benign neoplasm, rectum) or 235.2 (Neoplasm uncertain behavior, intestines and rectum [based on pathology report]).
Indication: Change in bowel habits, here for colon screening
Post-endoscopy findings: Normal colon
Procedure code: 45378
Do not append modifier 33 or PT, as this service was performed for a diagnostic, not screening, indication.
A visit prior to a screening colonoscopy for a healthy patient is not billable.
Yes. If the patient requires some intervention on the part of the gastroenterologist prior to the procedure, you can bill a New Patient or Established Patient visit, depending on whether the patient has received any face-to-face service by any provider of the same specialty in your office within the last three years.
No. Per Medicare guidelines, the procedure should be codes as a colonoscopy with a 53 modifier, which will pay a partial fee and allow you to repeat the procedure within the restricted time period and get full payment for the second procedure. Even if the scope was advanced beyond the splenic flexure, but the visualization was poor and the physician wants to repeat the procedure within the restricted time period, add the 53 modifier.
For all payors, if the procedure was initiated as a screening, the screening diagnosis is primary and the polyp is secondary. For example, on form CMS-1500 in the line with the polypectomy procedure code, in Box 24E (the diagnostic pointer box) enter a “2” linking the procedure with the polyp. In this way, the patient will receive the insurance benefits associated with screening procedures and the service will be paid correctly.
Yes. The time restrictions only apply between two screenings if the patient has no symptoms.
Given Medicare’s time restriction of two years between two high risk screenings and 10 years between two average risk procedures, if a screening is repeated in one year, it will be denied by Medicare as “not medically necessary.” If the physician wants to repeat the procedure within the restricted time, the first procedure should be billed with a 53 modifier, even though the scope advanced beyond the splenic flexure.
Effective Jan. 1, 2011, if a patient presents for a screening colonoscopy or flexible sigmoidoscopy (no GI symptoms), Medicare will waive both the deductible and coinsurance when billing the G codes for the screening.
If a polyp or lesion is found during the screening procedure, the colonoscopy becomes diagnostic and should be reported with the appropriate diagnostic colonoscopy code (45378-45392). For Medicare patients, the PT modifier would be appended to the code to indicate that this procedure began as a screening test. Medicare will still waive the deductible, but the patient will be responsible for the coinsurance.