1 CODING/BILLING Code Colonoscopies With Precision Accurate billing of these procedures requires attention to detail. (see ae rrr eee ro ae inserts long, flexible, cubular instrument called a colonoscope into the patient’s anus to examine the li for abnormalities and disease conditions. This type oftest may be performed asa colorectal cancer preventive screening, forsurveil- Iance reasons, or for diagnostic/therapeutic purposes. Here's what you need to know co correctly code colonascopies for all four encounter types. ing of the entire colon What Type of Colonoscopy sit? The first derail to consider is the purpose of the encounter. Colonoscopies fll into four basicencounter types: ‘Screening colonoscopy is provided to a patient in the absence of signsorsymptoms based on the patient sage, gender, medical history, and family history according to medical guidelines. Iris defined by the population on which the testis performed, not the results or findings ofthe est. As such, “screening” describes colonoscopy that is routinely performed on an asymptomatic person for the purpose oftes he presence of colorectal cancer or colorectal polyps. Diagnostic colonoscopy is performed when the patient has physical symptoms such as rectal bleeding or pain and the test is necessary to either rule out or confirm a suspected condition. Signs cused to explain the reason forthe test. are treated forthe purpose of biopsy, tamorablation, or ather therapy. lance colonoscopy is when the patient is asymptomatic buchasa personal history of gastrointestinal disease, colon polyps, or cancer. Technically this isa screening test with different diagnostic coding and frequency guidelines. Coding Colonoscopies eee oe ee eer eee eters re ee ee ere ees eel ae eae reecectce 36 Healthcare Business Monthiy By Shruthi Sargur Ravindranath, M.Sc, CPC Screening Colonoscopy Medicare coverage for preventive colonoscopies applies to patients aged 50 and older. As of 2022, the majority of commercial insurances cover screening colonoscopy for patientsaged 45 and older. And afew payerscovereven earlier forindividye alsathigh risk for colorectal cancer For commercial and Medicaid par tients,repart CPT" code 45378 Colo flexible; diagnostic, including collet ‘of specimens) by brushing or washing, when performed (eparate procedure). Nppend modifier Preventiveservceto the procedure code to rigger the preventive benefits (no cost-sharing) co che patient. Append modifier PTA colorectal cancersreningtet converted to diagnostic testo ater procedure to te proce- dure code fa screening tuned into diagnostic procedure, “Thisdoes not waive Medicare patents 20 percent coinsurance and/oracopay, butiewil waive che deductible. For Medicare patients, report HCPCS Level II code GO105 Colorectal cancer screening colonoscopy on individual at high risk ‘or GOI2i Colorectal cancer sreening; colonoscopy on individual not ‘meeting criteria for igh ri, as appropriate. Modifier 33 is noc used ‘on GO121 of GOIOS since screening is already indicated inthe code descriptions. ‘As you can see, you must know whether a Medicare patient is at high risk for colorectal cancer to select the right screening code. Per the Medicare Claims Processing Manual (Pub 104, Ch.18, See. 60), anindividual athigh riskfor colorectal cancer has + personal history ofadenomatous polyps, colorectal cancer, of inflammatory bowel disease, including Crohr'’s, disease and ulcerative colitis; and/or family history of familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer oF alos relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp.Colonoscopy Coding Note the words in bold. These Medicare guidelines are of- ten overlooked and, if not followed, wll result in claim denials ‘Commercial payers may allow additional levels offamily history, so always check policies for non-Medicare patients. Per the ICD-10-CM guidelines, "A screening code may be a firsclisted code ifthe reason for the visit is specifically for the sereeningexam.” Thatcode would be 712.11 Fneounerforscreening {for malignant neoplasm of colon. To indicate risk, code selection ‘will depend on the documented patient history (se the Medicare ‘Administrative Contractor’ local caverage determination forcolo- noscopy fora complete lst of diagnosis codes indicating high risk that are applicable to GO108}, To indicatea sreening colonoscopy is or surveillance ofa previous problem, be sure ro report the ap- plicable history code, provided itissupported in the medical record ‘Weve got ore great aces on the Knowledge Center at wwnwaapccor/blog “To indicate a screening colonoscopy is for surveillance of a previous Pel) a ONT e Clo (acl aig ale Mm celU ena supported in the medical record. “Another consideration is frequency. Medicare covers screening colonoscopy for patients at normal risk for colorectal cancer ‘once every 120 months (10 years) or 48 months after a previous sigmoidoscopy and once every 24 months for patients who are at high risk and/or require surveillance after findings from a previousscreening, Per Pub. 100-04, Medicare Claims Processing Manual, Ch.18, Sec. 60, start the “count beginning with the month afier the month in which a previous test/procedure was performed.” In other words, ifthe test was performed in March, begin counting from April Diagnostic/Therapeutic Colonoscopy Report CPT” cade 45378 for diagnostic colonoscopy ifthe scope reachesto the cecum; no modifier isallowed (see Figure 1). CPT" instructs you ro append modifier 53 Discontinued procedureto the code ifthe scope goes beyond the splenic flexure, but not all the way to the cecum. Ifthe scope does not reach the splenic flexure, then it is considered a flexible sigmoidoscopy, reported with Figure Late — Gotene fiere Transverse Rightcolic 45378-53 “lon (hepatie foxure 45330 Ascending condi wwwwaapccom March 2022 37 PTET)CODING/BILLING Colonoscopy Coding code 45330 Sigmoidoscop, flexible: diagnostic, including collection af specimen() by brushing or washing, when performed (ceparate procedure). As you can see, proper coding hinges on the physician documenting that information. Ifcherapeutic measures, such as polyp removal, are performed, select the colonoscopy code that most accurately describes what was done. Append modifier 52 Reduced rervicesto the code ifthe scope extends beyond the splenic flexure, but not as far as the ‘According to ICD-I0-CM/PCS Coding Clinic (First Quarter 2017), whenever a screening exam is performed, the screening codeisthefirstlisted, even ifan additional procedureis performed asa result of thescreening, In the event a screening turns diagnos- tic, also code the finding). foter When submitting a claim Tor the Taclity fee assochare with the procedure, ambulatory surgical centers (ASCs) should append the colonoscopy code with modifier 73 Procedure termi- natedidiscontinued before anesthesia is provided or 74 Procedure terminatedldiscontinued after anesthesia is induced or the procedure 4s initiated, as appropriac. (See Pub. 100-04, Medicare Claims Processing Manual, Ch. 4, Sec. 20.6.4.) Code by Example Ler’ look at a few coding examples for various colorectal cancer screeningencounters. ‘SCENARIO 1: ry ofcolon cancer ‘Screening colonoscopy ‘Coding: 0105, 780.0 for Medicare patients (no cost-sharing) 45378-33, 780.0 for Medicaid and commercial patients Rationale: For Medicaid and commercial patients, append. odifier 33 to the CPT* code ro eliminate patient cost-sharing, [copay, coinsurance, and deductible). ‘SCENARIO 2: Indication: Iron deficiency anemia, screening colon. Procedure performed: Colonoscopy (Coding: 45378, D50.9,Z12.11 Rationale: Screening is always performed on asymptomatic patients, As the reason for the visit is iron deficiency anemia, the test would be considered diagnostic even though a screening colonoscopy is specified. This scenario is considered a diagnostic colonoscopy so itis coded without modifiers 33/PT and the diag- nosisis sequenced before the encounter code. 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