Monday, June 7, 2010

CPT FLEXIBLE SIGMOIDOSCOPY - 45330, 45331

FLEXIBLE SIGMOIDOSCOPY - Procedure

Most used CPT List:

45330 Flexible sigmoidoscopy
45331 Flexible sigmoidoscopy with biopsy
45334 Flexible sigmoidoscopy with control of bleeding/argon laser coagulatioin

45338 Flexible sigmoidoscopy with removal of polyp


Definitions:

Sigmoidoscopy is the examination of the entire rectum and sigmoid colon, and includes examination of a portion of the descending colon.

Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum.

Indications and Limitations of Coverage and/or Medical Necessity

The following are Medicare-covered indications for diagnostic colonoscopy:
Evaluation of an abnormality on barium enema or other imaging study, which is likely to be clinically significant, such as filling a defect or stricture.

Evaluation of unexplained gastrointestinal bleeding:
Hematochezia not thought to be from rectum or perianal source,

Melena of unknown origin; after an upper GI source has been excluded,

Presence of fecal occult blood.

Unexplained iron deficiency anemia.

Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp.

Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management.

Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., with weight loss).

Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source).

Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasm, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).

Removal of foreign body.

Excision of colonic polyps.

Decompression of acute nontoxic megacolon or sigmoid volvulus, pseudo obstruction of the colon (Ogilvie’s syndrome).

Balloon dilatation of stenotic lesions (e.g., anastomotic strictures).

Palliative treatment of stenosing or bleeding neoplasm.

Marking a neoplasm for localization.

Evaluation of a patient with endocarditis due to streptococcus bovis or any bacterium of enteric origin.

Suspected disease of terminal ileum.

Evaluation of acute colonic ischemia/ischemic bowel disease.

In patients with Crohn’s colitis and chronic ulcerative colitis: colonoscopy every one or two years with multiple biopsies for detection of cancer and dysplasia in patients with:
Pancolitis of eight or more years duration; or

Left-sided colitis of 15 or more years duration.

Evaluation within 6 months of the removal of sessile polyps to determine and document total excision. If evaluation indicates that residual polyp is present, excision should be done with repeat colonoscopy within 6 months. After evidence of total excision without return of the polyp, repeat colonoscopy yearly.

Patients undergoing curative resection for colon or rectal cancer should undergo a colonoscopy 1 year after the resection (or 1 year following the performance of the colonoscopy that was performed to clear the colon of synchronous disease).

A diagnostic colonoscopy is not considered medically necessary for the following conditions:
Chronic, stable, irritable bowel syndrome or chronic abdominal pain. There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy.

Acute limited diarrhea.

Hemorrhoids.

Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management.

Routine follow-up of inflammatory bowel disease (except for cancer surveillance in Crohn's colitis, chronic ulcerative colitis).

Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease.

Upper GI bleeding or melena with a demonstrated upper GI source.

A diagnostic flexible sigmoidoscopy is covered for the following indications:
Evaluation of suspected distal colonic disease when there is no indication for a colonoscopy.

Evaluation for anastomotic recurrence in rectosigmoid carcinoma.

All of the covered indications listed for a diagnostic colonoscopy.

A diagnostic flexible sigmoidoscopy is not indicated when a colonoscopy is indicated.



Sigmoidoscopy Service Codes

Code                           Description

45330              Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

45331              Sigmoidoscopy, flexible; with biopsy, single or multiple
45332              Sigmoidoscopy, flexible; with removal of foreign body
45333              Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

45334              Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45335               Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45337               Sigmoidoscopy, flexible; with decompression of volvulus, any method
45338               Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45339               Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45340               Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures
G0104              COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY
G0106              COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA.

45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination

45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)

45345 Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)

45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes preand  post-dilation and guide wire passage, when performed)

45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection

45350 Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids)

G6022 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesions(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique


G6023 Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)



Limitations:


Endoscopy is generally not covered for treating the following, and records must have additional documentation indicating the medical necessity of the procedure for review as needed:

1. Chronic, stable, irritable bowel syndrome, or chronic abdominal pain. There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy

2. Acute diarrhea

3. Hemorrhoids

4. Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management

5. Routine follow-up of inflammatory bowel disease (except for cancer surveillance in Crohn’s disease and chronic ulcerative colitis)

6. Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease

7. Upper gastrointestinal (GI) bleeding or melena with a demonstrated upper GI source; or,

8. Bright red rectal bleeding with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source

Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy are generally not covered for:

1. Fulminant colitis

2. Possible perforated viscus

3. Acute severe diverticulitis; or,

4. Diverticulosis- This condition is not usually considered an indication for diagnostic or therapeutic colonoscopy, sigmoidoscopy or proctosigmoidoscopy, but may be reported on the claim when this condition is found to be the final diagnosis.

Marking of a neoplasm for localization (tattooing) is covered, but is not separately payable.


Billing and Coding Guideliens

SIGMOIDOSCOPY within the measurement period or prior four years (Valid dates = 07/01/2009 to 06/30/2014). See Tables 4-6.

** Using claims codes: Provide the service date and code associated  with the sigmoidoscopy procedure.

o Accepted sigmoidoscopy CPT procedure codes: 45330-45335, 45337-45342, 45345.
o Accepted sigmoidoscopy ICD-9 procedure codes: 45.24.
o Accepted sigmoidoscopy HCPCS codes: G0104.


Code G0104 (colorectal cancer screening; flexible sigmoidoscopy) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic flexible sigmoidoscopy (CPT code 45330). (The same RVUs have been assigned to code G0104 as those assigned to CPT code 45330.) If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the
appropriate procedure classified as a flexible sigmoidoscopy with biopsy or removal must be billed and paid rather than code G0104.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0320 - 0329
0360 - 0369
0450 - Emergency Room: General Classification
0490 - 0499
0510 - 0519
0520 - 0529
0750 - Gastro-Intestinal Services: General Classification
0760 - 0769



Codes to Identify Flexible Sigmoidoscopy:
CPT: 45330-45335, 45337-45342, 45345, G0104
ICD9 Procedure Codes: 45.24


Colorectal Cancer (CRC) Screening

The Colorectal Cancer Screening quality measure assesses whether adults 50–75 years of age have had appropriate screening for CRC. “Appropriate screening” is defined by meeting any one of these screening methods:

•Fecal occult blood test (FOBT) during the current year.
•Flexible sigmoidoscopy in the current year or the preceding four years.
•Colonoscopy in the current year or the preceding nine years.

WHAT CODES DO I FILE?
When filing claims in the future, you can help improve our awareness of the services you provide related to CDCs by using these codes:

Flexible Sigmoidoscopy
CPT Codes: 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, 45345

HCPCS Codes: G0104


General Information

The Patient Protection and Affordable Care Act (PPACA) provides coverage for preventive screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. In addition, in October 2015 the United States Department of Labor issued clarification that related ancillary services are also to be covered at the preventive services benefit level.



A. Colorectal Cancer Screening Services

Moda Health covers the preventive screening for colorectal cancer in accordance with the Patient Protection and Affordable Care Act (PPACA) at 100% (no cost-sharing responsibility to the member), when the member is seeing an in-network provider.

Colorectal cancer screening may be performed using fecal occult blood testing, sigmoidoscopy, colonoscopy, or barium enema alternative colorectal cancer screening.


D. Screening Colonoscopy Or Sigmoidoscopy When No Abnormalities Are Found

If a screening colonoscopy is performed and no abnormalities are found, submit the service with a procedure code specific to a screening colonoscopy (e.g. G0105, G0121).

If a screening sigmoidoscopy is performed and no abnormalities are found, submit the service with a procedure code specific to a screening sigmoidoscopy (e.g. G0104).


E. Screening Colonoscopy Or Sigmoidoscopy Converted To Diagnostic Or Therapeutic Colonoscopy Or Sigmoidoscopy

When an abnormality is encountered during screening colonoscopy or sigmoidoscopy:

* The colonoscopy or sigmoidoscopy is still classified as a preventive service eligible for coverage at the no-member-cost-share benefit level.

o Submit the claim with Z12.11 (Encounter for screening for malignant neoplasm of colon) as the first-listed diagnosis code; this is the reason for the service or encounter. Use of Z12.11 in the first diagnosis position is essential to ensure the member’s PPACA no-cost-share benefits are accessed.

o Modifier PT is to be appended to the appropriate diagnostic or therapeutic colonoscopy procedure code(s).

o Claims with diagnostic colonoscopy/sigmoidoscopy procedure codes submitted without modifier PT appended or without Z12.11 as the first-listed diagnosis code will be processed under the member’s normal medical benefit level, not preventive benefits.

* Future colonoscopies or sigmoidoscopies are no longer eligible for Preventive screening benefits under the Patient Protection and Affordable Care Act (PPACA); they are considered diagnostic, monitoring or surveillance testing (see  onitoring or Surveillance Testing below).


Screening flexible sigmoidoscopy:

Medicare covers a screening flexible sigmoidoscopy once every 4 years for beneficiaries 50 and older. If a beneficiary had a screening colonoscopy in the previous 10 years, then the next screening flexible sigmoidoscopy would be covered only after 119 months have passed following the month in which the last screening colonoscopy was performed. A doctor of medicine or osteopathy, a physician assistant, a nurse practitioner, or a clinical nurse specialist may perform a screening flexible sigmoidoscopy.

Screening barium enema: Medicare covers a screening barium enema as an alternative to a screening flexible sigmoidoscopy for all beneficiaries under the same coverage requirements and at the same frequency as for the screening flexible sigmoidoscopy. Medicare will cover only one such service during the coverage timeframe: it will cover either the screening flexible sigmoidoscopy or the barium enema, but not both.

 Starting January 1, 2007, the Medicare Part B deductible has been waived for screening colonoscopy, sigmoidoscopy, and barium enema (as an alternative to colonoscopy or sigmoidoscopy). However, the deductible is not waived if the colorectal cancer screening test becomes a diagnostic colorectal test; that is the service actually results in a biopsy or removal of a lesion or growth.

• Starting January 1, 2007, for a screening flexible sigmoidoscopy or a screening colonoscopy performed in a non-outpatient prospective payment system hospital outpatient department, the beneficiary is liable for paying 25% of the Medicare-approved amount (the coinsurance). The 25% coinsurance is currently being applied in the Outpatient Prospective Payment System (OPPS) for OPPS hospitals. However, it is not being applied to non-OPPS hospitals. Starting January 1, 2007, for a screening colonoscopy performed in an ambulatory surgical center, the beneficiary is liable for paying 25% of the Medicare-approved amount (the coinsurance).

In addition, G0107 (FOBT, 1-3 simultaneous determinations) has been discontinued. CPT code 82270 (patient was provided 3 single cards or single triple card for consecutive collection) has been adopted to encourage quality colorectal cancer screening.

HCPCS/CPT Code Code Descriptors

G0104 Colon cancer screening; flexible sigmoidoscopy
G0105* Colon cancer screening; colonoscopy on individual at high risk
G0106 Colon cancer screening; barium enema as an alternative to G0104
82270 Colon cancer screening; FOBT, patient was provided 3 single cards or single triple card for consecutive collection
G0120 Colon cancer screening; barium enema as an alternative to G0105
G0121 Colon cancer screening; colonoscopy for individuals not meeting criteria for high risk

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