Tuesday, August 3, 2010

Colonoscopy coding - CPT 45378,G0105,G0121 list


Colonoscopy Codes:

45378 Diagnostic/screening colonoscopy for non-medicare patients. Fee amount $381.1
G0105 Screening Colonoscopy for medicare high risk patients
G0121 Screening colonoscpy for other medicare patients.


Definitions of Colonoscopy and Sigmoidoscopy:

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.



CPT/HCPCS Codes list


44388 Colonoscopy thru stoma spx

44389 Colonoscopy with biopsy

44390 Colonoscopy for foreign body

44391 Colonoscopy for bleeding

44392 Colonoscopy & polypectomy

44394 Colonoscopy w/snare

44401 Colonoscopy with ablation

44402 Colonoscopy w/stent plcmt

44403 Colonoscopy w/resection

44404 Colonoscopy w/injection

44405 Colonoscopy w/dilation

44406 Colonoscopy w/ultrasound

44407 Colonoscopy w/ndl aspir/bx

44408 Colonoscopy w/decompression

45330 Diagnostic sigmoidoscopy

45331 Sigmoidoscopy and biopsy

45332 Sigmoidoscopy w/fb removal

45333 Sigmoidoscopy & polypectomy

45334 Sigmoidoscopy for bleeding

45335 Sigmoidoscopy w/submuc inj

45337 Sigmoidoscopy & decompress

45338 Sigmoidoscopy w/tumr remove

45340 Sig w/tndsc balloon dilation

45341 Sigmoidoscopy w/ultrasound

45342 Sigmoidoscopy w/us guide bx

45378 Diagnostic colonoscopy

45379 Colonoscopy w/fb removal

45380 Colonoscopy and biopsy

45381 Colonoscopy submucous njx

45382 Colonoscopy w/control bleed

45384 Colonoscopy w/lesion removal

45385 Colonoscopy w/lesion removal

45386 Colonoscopy w/balloon dilat

45391 Colonoscopy w/endoscope us

45392 Colonoscopy w/endoscopic fnb



How to Code Colonoscopy

Colonoscopy is the examination of the entire colon from the rectum to cecum. A colonoscope is inserted in the anus and moved through the colon past the splenic flexure in order to visualize the lumen of rectum and colon.

Always a surgical endoscopy includes a diagnotic endoscopy.

For an incomplete colonoscopy, with full preparation for a colonoscopy, use a colonoscopy code with the modifier 52 and provide information.

A diagnostic colonoscopy is a screening of the colon for any abnormalities without performing any procedure.

A colonoscopy with biopsy, polypectomy, or any removal of foreign body or any other intervention is not considered as diagnostic colonoscopy.


Colonoscopy with other procedures.

45379 Colonoscopy with removal of foreign body.
45380 Colonoscopy with biopsy single/multiple.
45381 Colonoscopy with directed submucosal injection.
45382 Colonoscopy with control of bleeding.

Polyps or lesions are removed by hot biospy, cold biopsy, and snare techniques. Depending on the technique the codes are differentiated.

45383 Colonoscopy with ablation of tumors, polyps, or other lesions not amenable to removal by hot biopsy forceps.
45384 removal of polps or other lesions by hot biopsy
45385 removal of polyps or lesions by snare technique.



Colonoscopy

The definition of a colonoscopy examination is now specifically described in CPT as the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.

 When performing a diagnostic or screening procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.

 If a therapeutic examination colonoscopy is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

Screening colonoscopy for a low risk patient with no findings during the colonoscopy.  The colonoscopy procedure code: o 45378 with modifier 33 indicating that the service was preventive OR o G0121 The screening diagnosis code: o V76.51

Guidelines 

New definition. Colonoscopy is the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis. For screening or diagnostic colonoscopy, report 45378 with modifier 53 if unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances and provide appropriate documentation. For therapeutic examinations that do not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

Screening Colonoscopy and Evaluation & Management Service on the Same Day

Typically, patients referred for a screening colonoscopy do not have signs or symptoms that support a diagnostic colonoscopy.

The physician performing the colonoscopy may wish to see and evaluate the patient prior to the screening colonoscopy. In this case, the evaluation and management (E/M) visit is generally not separately billable.

Even though some patients may be at high risk for the procedure due to concurrent conditions that may affect the decision to perform the procedure, the patient evaluation for these risk factors is included in the usual pre-service work associated with the screening colonoscopy.

A separate E/M service may be submitted for patients that are referred for a screening colonoscopy when either of the following scenarios occurs either when:

All the required components of the E/M are documented and based on this evaluation the physician decides not to proceed with the procedure

All the required components of the E/M are documented and the physician determines the patient has signs and symptoms that warrant a diagnostic colonoscopy instead of the screening colonoscopy


It is also important to remember that when a screening colonoscopy detects a lesion or growth resulting in a biopsy or removal of the growth, the appropriate diagnostic colonoscopy with biopsy or removal code must be submitted rather than the screening colonoscopy code.


Modifier 51 Examples

• Colonoscopy (45378) performed at the same session as upper endoscopy (43200). Use modifier 51 on the upper endoscopy (43200) because the RVU’s are lower than the colonoscopy (45378). 45378, 43200-51.

Correct Use of Modifier PT 

Screening Colonoscopy or Flexible Sigmoidoscopy converted to diagnostic test or therapeutic procedure.
CPT Codes:  45378-45392,
45331-45345,
G0104-G0106,
G0120-G0121, 74270

No copay applies when Modifier PT is added to the diagnostic test or therapeutic procedure code.

Deductible is waived for surgical services related to the colonoscopy / sigmoidoscopy on the same day as the screening test.


Modifiers 33 and PT are key components to submitting accurate preventive services claims; as such, it’s important to review and become familiar with the following billing guidance.

This modifier may be used to identify when a service was initiated as a preventive service, which then resulted in a conversion to a therapeutic service. The most notable example of this is screening colonoscopy (code 45378), which results in a polypectomy (code 45383).

7 Q: How will the Endoscopic Adjustment Rule be applied to multiple endoscopy codes within the same family (same Endoscopic Base Code) billed on the same day by the Same Group Physician and/or Other Health Care Professional on or after 12/1/2016 date of service  ?


A: Below is an example of how the Endoscopic Adjustment Rule will be applied on multiple procedure

** In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon.

The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), the Endoscopic Adjustment Rule will pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).

** Based on the following fee schedule amounts for these codes if the procedures were performed in a facility: 45378 ($255.40), 45380 ($285.98), 45385 ($374.56)

** Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.


Code       Facility RVU      Fee Schedule        Endoscopy Reduction       Adjusted Allowable


45378  6.48  255.40  Base code = Not allowed   0


45380  7.73  285.98  285.98 - 255.40  30.58

45385  9.17  374.56 Highest RVU – no reduction 374.56


BCBS Guideline

The BCBSMA Policy is predicated on the reason the colonoscopy visit was scheduled. If the visit was scheduled as routine and a finding was discovered during the procedure, the visit is considered routine. Please see the sample billing guidelines below:

If the service is a:    Screening colonoscopy for a low risk patient with no findings during the colonoscopy

The colonoscopy procedure code:

o 45378 with modifier  33 indicating that the service was preventive OR o G0121

The screening diagnosis code:

o V76.51


If the service is a:  Diagnostic colonoscopy performed due to signs or symptoms, or to ruleout or confirm a suspected diagnosis


Procedure                  Diagnosis

The colonoscopy procedure code:

o 45378 WITHOUT  modifier 33

o DO NOT use the G screening codes listed above


Medicare Guidelines


Effective for services performed on or after January 1, 2016, the Medicare Physician Fee Schedule (MPFS) database will have specific values for Current Procedural Terminology (CPT) codes 44388-53; 45378-53; G0105-53; and G0121-53


Background

According to CPT instruction, prior to calendar year (CY) 2015, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Physicians were previously instructed to report an incomplete colonoscopy with 45378 and append Modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy.

In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states:

“When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.”

Therefore, in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) has applied specified values in the Medicare Physician Fee Schedule (MPFS) database for the following codes:

** 44388-53 (colonoscopy through stoma);

** 45378-53 (colonoscopy);

** G0105-53 (colorectal cancer screening; colonoscopy on individual at high risk; and

** G0121-53 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).


Digestive System

Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)

An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.


QUESTION: Is there a difference regarding the use of modifiers 52 and 53 with regards to upper and lower endoscopic procedures?

ANSWER: Yes.

EGD procedures: To report esophagogastroscopy where the duodenum is deliberately not examined (e.g., judged clinically not pertinent) or because significant situations preclude such exam (e.g., significant gastric retention precludes safe exam of duodenum), append modifier 52, if repeat examination is not planned, or modifier 53, if repeat examination is planned.

• Example: EGD is performed and a tube is placed into the stomach. The duodenum is not examined and there is no plan to perform repeat EGD to examine the duodenum. Report procedure with modifier 52.

• Example: EGD is performed for evaluation of GI bleeding; the stomach is full of blood and the duodenum is not examined. Plan to control bleeding, lavage stomach and repeat upper endoscopy. Report procedure with modifier 53.

 Colonoscopy procedures:

• When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.

• If a therapeutic colonoscopy (44389-44407, 45379, 45380, 45381, 45382, 45384, 45388,45398) is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.


QUESTION: What are the CPT and ICD-10 codes for screening and surveillance colonoscopy?

ANSWER: Check with the payor as to which codes to bill the colonoscopy and the acceptable ICD-10 codes.

Payors other than Medicare may allow additional ICD-10 codes for meeting criteria for screening and surveillance colonoscopy.

Billing for a screening colonoscopy in an average-risk patient:

• G0121 (Medicare) or 45378 (Medicaid, commercial, exchange, Tricare) with the appropriate ICD-10 code for screening:

Z12.11 — encounter for screening for malignant neoplasm of colon.

Z12.12 — encounter for screening for malignant neoplasm of rectum.

Billing for screening colonoscopy in a high-risk patient:

• G0105 (Medicare) or 45378 (Medicaid, commercial, exchange, Tricare) with the appropriate ICD-10 code for screening:

 K50 — Crohn’s disease.

 K51 — ulcerative colitis.

 K52.1 — toxic gastroenteritis and colitis.

 K52.89 — other specified noninfective gastroenteritis and colitis.

 K52.9 — noninfective gastroenteritis and colitis, unspecified.

 Z85.038 — personal history of other malignant lesion of large intestine.

 Z85.048 — personal history of other malignant lesion of rectum, rectosigmoid junction and anus.

 D12.6 — benign neoplasm of colon, unspecified.

Z15.09 — genetic susceptibility of other malignant neoplasm.

 Z80.0 — family history of malignant neoplasm of digestive organs.

 Z83.71 — family history of colonic polyps.

 Z86.010 — personal history of benign neoplasm of colon.




•When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 (discontinued procedure) and provide appropriate documentation.

EMR Colon 2015 Medicare

• G6021 Unlisted service, colon – By itself or as secondary code to snare removal code

• Flex sig: 45338 + 45399

• Colon through stoma: 44394 + 45399

• Colonoscopy: 45385 + 45399

• Cover letter “colonoscopy counterpart to 43254 EGD with EMR” can suggest same $ increment (43254-43235) be added to 45378


4 comments:

  1. what would be the appropriate modifier to use if the hospital is billing an incomplete screening colonoscopy on a medicare patient?

    ReplyDelete
  2. if an office visit for a screening is done then the actually colonoscopy was done a month later, why does Blue Cross only pay for one? Just because of the diagnosis code? That doesn't seem fair.

    ReplyDelete
  3. This article is very helpful to learn more about the process colonoscopy.

    ReplyDelete

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