Colonoscopy Screenings and Related Subsequent Diagnostic Procedures

Coding Tip for Preventing Service and Screening

When a provider performs a separately identifiable medically necessary E/M service in addition to the IPPE, CPT codes 99201-99215 reported with modifier -25 may also be billed. When medically indicated, this additional E/M service would be subject to the applicable copayment for office visits.

Colonoscopy Screenings and Related Subsequent Diagnostic Procedures

Currently, in all UnitedHealthcare Medicare Advantage plans, a colonoscopy that begins as an in-network screening service is subject to the $0 screening cost-share regardless of whether a polyp is found and/or removed during the procedure.

Coding:
•    Endoscopy codes G0104, G0121 or G0105 are used for screening colonoscopies. These continueto assess a $0 in-network cost-share per the Medicare preventive services coverage guidelines.
•    CPT Code 45330 (and family codes) and CPT Code 45378 (and family codes) billed with
modifier PT are used if a screening turns into a diagnostic procedure. These codes, when billed
with the PT modifier, will assess the $0 in-network cost-share. If the colonoscopy service is billed without the PT modifier, the claim will be processed as a surgery and the applicable cost-share will apply.
•    Providers may not bill both the screening and the diagnostic services when a screening
colonoscopy turns into a diagnostic procedure. Only the diagnostic code with the PT modifier
may be billed in these circumstances.
•    If the screening service and subsequent diagnostic procedure is performed at an out of network facility, applicable cost-shares will be assessed.

Details
The Welcome to Medicare Visit is a one-time preventive evaluation and management service that includes the following services:
1. Review of the member’s medical and social history.
2. Review of the member’s potential risk factors for depression.
3. Review of the member’s functional ability and level of safety, including hearing impairment,
daily living activities, fall risk and home safety.
4. An exam to include height, weight, body mass index, blood pressure, visual acuity and other
measurements.
5. End-of-life planning assistance such as an advance directive or health care proxy, with the
member’s consent.
6. Education, counseling and referral based on the results of numbers 1-5 in this list.
7. Education, counseling and referral, including a brief written plan for obtaining a screening EKG, as appropriate, and other appropriate screenings and/or Medicare Part B preventive services.

The Annual Wellness Visit allows the physician and member to develop a personalized prevention plan that considers age-appropriate preventive services plus additional services based on the patient’s health status. The visit may include at least the following services:
1. Establish or update the member’s medical and family history.
2. Review the member’s potential risk factors for depression.
3. Review the member’s functional ability and level of safety, including hearing impairment, daily
living activities, fall risk and home safety.
4. An exam to include height, weight, body mass index, blood pressure and other routine measurements.
5. List or update the list of the member’s medical providers and suppliers.
6. Detect any cognitive impairment the member may have.
7. Establish or update a screening schedule for the next five to 10 years, as appropriate.
8. Establish or update the member’s list of risk factors.
9. Personalized health advice and appropriate referrals to health education or preventive services.

The Pap/Pelvic Exam (also known as the Well Woman Exam) should include at least seven of the following elements:

1. Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple
discharge
2. Digital rectal examination including sphincter tone and presence of hemorrhoids or rectal masses
3. Examination of external genitalia (for example, general appearance, hair distribution, or lesions)
4. Examination of urethral meatus (for example, size, location, lesions, or prolapse)
5. Examination of urethra (for example, masses, tenderness, or scarring)
6. Examination of bladder (for example, fullness, masses, or tenderness)
7. Examination of vagina (for example, general appearance, estrogen effect, discharge, lesions,
pelvic support, cystocele, or rectocele)
8. Examination of cervix (for example, general appearance, lesions, or discharge)
9. Specimen collection for pap smears and cultures.

The purpose of the Annual Routine Physical Exam is to provide a comprehensive physical examination in order to screen for disease, promote a healthy lifestyle, and assess a member’s potential risk factors for future medical problems. Any clinical laboratory tests or other diagnostic services performed at the time of the wellness visit may be subject to a copayment or coinsurance.

This exam includes performance of all of the following components as well as the gender-specific examination:
1. History
2. Vital signs
3. General appearance
4. Heart exam
5. Lung exam
6. Head and neck exam
7. Abdominal exam
8. Neurological exam
9. Dermatological exam
10. Extremities exam
11. Male physical exam
Testicular, hernia, penis, and prostate exams
12. Female physical exam
Breast and pelvic exams
13. Counseling to include healthy behaviors and screening services

Separate codes for these components may not be billed in conjunction with 99385-99387 or 99395-99399. Payment for these codes includes reimbursement for all services listed above.