The first detail to consider is the purpose of the encounter. Thank you for this information regarding Colonoscopy procedures. Rationale: The intent of the study was screening colonoscopy, but a polyp was removed during the procedure, which converted the screening colonoscopy to a diagnostic/therapeutic colonoscopy. When I looked at the denial cases all of them had polyp findings and per the tabular tip under Z12.11, I recommended resubmitting without Z17.11 but with the polyp findings. Per the ICD-10-CM guidelines, A screening code may be a first-listed code if the reason for the visit is specifically for the screening exam. That code would be Z12.11 Encounter for screening for malignant neoplasm of colon. NXFe*Q5=2apG]J?svbX9h ]5P=\H'9}21>_.7mU&^nwJ~2*fDxPQd7/;G?hl 20.6.4.). cNdu9VY8QskPQSY6QKEO$!V -YO/-zVG,%3f8TcpHvPA-t13t6rxepF\>Q8UJC(Kr 3A y)tjdTCB^kY2?9w.wfqJ(|1'JQ^[myHoTx[9[]- Latest posts by Shruthi Sargur Ravindranath. There was a statement from the Pathologist with a diagnosis Pathology report same day consistent with Lymphocytic Colitis Dx used was K529 Inflammation of stomach and intestine. Shruthi Sargur Ravindranath, M.Sc, CPC, has more than 14 years of experience in medical coding and a masters in zoology. Report the appropriate CPT code with modifier 33/PT appended, depending on the payer. For claims with dates of service on or after Jan. 2, 2016, report with CPT code 81528, For claims with dates of service on or after Jan. 19. Several cousins with confirmed diagnosis of Celiac disease. Stacy, modifier 74 is not applicable for screening colonoscopy G code, so for the cancelled or discontinued screening cases you need to bill with modifier 53. We are being told to use the G codes with a modifier 74 if the procedure is cancelled. Fecal occult blood tests (FOBTs) once every 12 months. The patient was left with $877 bill any ideas on how this patient bill could be reduced? This type of test may be performed as a colorectal cancer preventive screening, for surveillance reasons, or for diagnostic/therapeutic purposes. 0 Per the Medicare Claims Processing Manual (Pub 104, Ch.18, Sec. Per Pub. !Cv 1d_rdD/i+2P9l Vmo=J1J&00r}cdAm&ie_@,dcaCq"^coXC2/I)wE`n2x%>8QGKMhPL2CZ&a-h }Ee*ROZ(j'Ztb|.my9x6hy(k"PeLy'_N?_>#SxR.xu*#6 hOP\E1x2GLp9GQ>i* $N7[H&nA:Y3;0zU5?Q|h16~l+Ry>;ugtdd/Y)!c9E9U=\]x=,!^AY Report CPT code 45378 for diagnostic colonoscopy if the scope reaches to the cecum; no modifier is allowed (see Figure 1). Modifier 33 is not used on G0121 or G0105 since screening is already indicated in the code descriptions. 100-04, Medicare Claims Processing Manual, Ch.18, Sec. In the event a screening turns diagnostic, also code the finding(s). Update (May 4, 2022): Please see MLN Matters article MM12656 for changes to Medicare coinsurance for additional procedures furnished during the same clinical encounter as certain colorectal cancer screening tests. ce`r;QLfS As you can see, you must know whether a Medicare patient is at high risk for colorectal cancer to select the right screening code. Colonoscopies fall into four basic encounter types: Screening colonoscopy is provided to a patient in the absence of signs or symptoms based on the patients age, gender, medical history, and family history according to medical guidelines. However, a few of the commercial insurances will cover the visit with code S0285 Colonoscopy consultation performed prior to a screening colonoscopy procedure. As a new coder, this knowledge is great to have handy to read over a few times. We had received denials for Z12.11 in the secondary position. Rita, usually Z12.11 is not used when there are high-risk codes (Z86.010, Z83.71, Z80.0). Note: When submitting a claim for the facility fee associated with the procedure, ambulatory surgical centers (ASCs) should append the colonoscopy code with modifier 73 Procedure terminated/discontinued before anesthesia is provided or 74 Procedure terminated/discontinued after anesthesia is induced or the procedure is initiated, as appropriate. Indication: Family history of colon cancer, Procedure performed: Screening colonoscopy, Coding: G0105, Z80.0 for Medicare patients (no cost-sharing), 45378-33, Z80.0 for Medicaid and commercial patients. Signs and symptoms are used to explain the reason for the test. When a screening colonoscopy turns into a diagnostic colonoscopy, report the anesthesia service with CPT 00811 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified with modifier PT. I3w~P(r\z1POx[M;^"XZcNS +Sh9p This is great information! The screening code (Z12.11) would be sequenced first, followed by the findings. Indication: Iron deficiency anemia, screening colon. Hello, 60), an individual at high risk for colorectal cancer has: Note the words in bold. As the reason for the visit is iron deficiency anemia, the test would be considered diagnostic even though a screening colonoscopy is specified. Earn CEUs and the respect of your peers. Append modifier PT A colorectal cancer screening test converted to diagnostic test or other procedure to the procedure code if a screening turned into a diagnostic procedure. We are looking for thought leaders to contribute content to AAPCs Knowledge Center. He did not discontinue the procedure at any point. Your email address will not be published. {yB_\^|_O_{_w}wU-7-7w?{1w~c&~z+}?_g7co>VVX9}$/~natgam5;RbT!rh[u"'!- As such, screening describes a colonoscopy that is routinely performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. To indicate risk, code selection will depend on the documented patient history (see the Medicare Administrative Contractors local coverage determination for colonoscopy for a complete list of diagnosis codes indicating high risk that are applicable to G0105). As an alternative to colonoscopy, Medicare covers additional types of colorectal cancer screening tests. The plan paid $1509 of the Plan Allowed Amount of $2386, however the codes indicated Not a Covered Service (not medically necessary). Chastity, if the patient is coming for a screening colonoscopy, then Z12.11 should be sequenced as PDx followed by findings provided there is no LCD list. Therapeutic colonoscopy is performed when the abnormalities are treated for the purpose of biopsy, tumor ablation, or other therapy. Another consideration is frequency. Commercial payers may allow additional levels of family history, so always check policies for non-Medicare patients. Do we use CPT 45378 or G0121, or G0105? 2021, blood-based biomarker tests are paid under the Clinical Laboratory Fee Schedule with HCPCS Level II code G0327. Moderate sedation is reported with HCPCS Level II code G0500 or, if warranted, CPT code 99152-33 and 99153-33 based on time. CPT instructs you to append modifier 53 Discontinued procedure to the code if the scope goes beyond the splenic flexure, but not all the way to the cecum. Medicare covers the Cologuard multi-target stool DNA (MT-sDNA) test once every three years for patients aged 50-85 years who are asymptomatic and at average risk for colorectal cancer. Thank you. Doesnt the Z12.11 code trigger that the exam was a screening? There seems to be some confusion about whether you bill it Z1211, Z86010. aJ~7UR&P-?#H6C/i1fx. For Medicare patients, report HCPCS Level II code G0105 Colorectal cancer screening; colonoscopy on individual at high risk or G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk, as appropriate. %PDF-1.7 % Appending modifier PT will waive the Medicare deductible but not the coinsurance. As a contributor you will produce quality content for the business of healthcare, taking the Knowledge Center forward with your knowhow and expertise. endstream endobj startxref Rationale: For Medicaid and commercial patients, append modifier 33 to the CPT code to eliminate patient cost-sharing (copay, coinsurance, and deductible). In knowing the reason for the encounter preventive, diagnostic, therapeutic, or surveillance you can select the appropriate procedure code based on the patients age, risk for colorectal cancer, and insurance (not to mention fee schedule). Your email address will not be published. For commercial and Medicaid patients, report CPT code 45378 Colonoscopy, flexible; diagnostic, including collection of specimens(s) by brushing or washing, when performed (separate procedure). And a few payers cover even earlier for individuals at high risk for colorectal cancer. For a screening colonoscopy: For commercial and Medicaid patients, report CPT code 45378 Colonoscopy, flexible; diagnostic, including collection of specimens(s) by brushing or washing, when performed (separate procedure). Ravindranath is a member of the Bangalore, India, local chapter. %%EOF Technically, this is a screening test with different diagnostic coding and frequency guidelines. These Medicare guidelines are often overlooked and, if not followed, will result in claim denials. What if 2 polyps are removed by 2 different means (snare, hot bx) do you put mod- PT and Z code as primary on both lines or just one? However, I would need to know the exact denial reason to answer this question along with MAC and state. According to ICD-10-CM/PCS Coding Clinic (First Quarter 2017), whenever a screening exam is performed, the screening code is the first listed, even if an additional procedure is performed as a result of the screening. Guess Ive been doing my coding per your report. Is this incorrect? Could you please explain how to bill a colonoscopy for some one with a history of colon polyps, Z86010. Or just Z86010. endstream endobj 3045 0 obj <>>>/Lang(en-US)/MarkInfo<>/Metadata 127 0 R/Outlines 140 0 R/Pages 3042 0 R/StructTreeRoot 159 0 R/Type/Catalog>> endobj 3046 0 obj <>/MediaBox[0 0 612 792]/Parent 3042 0 R/Resources<>/ProcSet[/PDF/Text]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 3047 0 obj <>stream Also, if Z code is removed, then the patient would be losing the screening benefit. Medicare coverage for preventive colonoscopies applies to patients aged 50 and older. Question please: can I bill the insurance for a follow up visit post colonoscopy screening if the findings are adenomas ex tubular adenomas. She is experienced in multiple specialties including E/M, gastroenterology, surgery, anesthesia, internal medicine, general surgery, and radiology. Append modifier 52 Reduced services to the code if the scope extends beyond the splenic flexure, but not as far as the cecum. If therapeutic measures, such as polyp removal, are performed, select the colonoscopy code that most accurately describes what was done. @NNy"dr:Q`da lyNDOEY/#{)w,]30P>buP0kMP!X!,=LLjHO.*rkx>!Q9'%n0u'kQ -14r]&`G"kKnQ[RAxPnFRFl=3 (Se U :gr9PGsg>b:+zT;5ZuCK 3064 0 obj <>/Filter/FlateDecode/ID[<637A0E9212779343A9120E8290A7ED9D>]/Index[3044 47]/Info 3043 0 R/Length 94/Prev 382074/Root 3045 0 R/Size 3091/Type/XRef/W[1 2 1]>>stream Question What modifier would be appropriate if patient is having a screening (or a surveillance) colonoscopy, scope goes to the cecum and a polyp is removed, however, prep is poor and not everything can be visualized and doctor wants to repeat in a month with longer prep. If the scope does not reach the splenic flexure, then it is considered a flexible sigmoidoscopy, reported with code 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure). (See Pub. You will need to check the payers policy. Would this be a 53 or 52? 4, Sec. As you can see, proper coding hinges on the physician documenting that information. Hello, 4~cGcC*G*Xfd!!~Nf+BU;#*>AZu` document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Copyright 2022, AAPC This scenario is considered a diagnostic colonoscopy so it is coded without modifiers 33/PT and the diagnosis is sequenced before the encounter code. I understand some payors require the -33 be on when submitted with 45378 but I do not think this is the case with ALL commercial screenings. Append modifier 33 Preventive service to the procedure code to trigger the preventive benefits (no cost-sharing) to the patient. Thank you in advance for your help! hbbd``b`q@DP$@@:u$ &% 1G KH x Qb% N .@K 0 c Hello. It is defined by the population on which the test is performed, not the results or findings of the test. Patient had been billed CPT 45380 Intestinal Exam and 43239 Scope exam with biopsy, G0500 Sedation by doctor, 99153 Sedation with observ. Is modifier -33 required for code 45378 when a commercial patient only has a screening done? 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 previous screening. 'K>@&zW,SWB~q.Kr1"fCy4Hm&0j=tNz-1+:/'+M2yT8hce]km/X, Tb1~F+#b?N|L),'!5>934_{E~~s])p":/0bGZkCh.*%u.6~bo;g]6wm!pFGjX\1pGVFi>Ov I have a question for a screening colonoscopy: If the scope goes past the splenic flexure and cancelled because of poor bowel prep, or other reason, would you use the G code with modifier -74 for an OP facility? >p:!T&s=+m\m .1BcDj`0h`` P~(*4P%"($DT/%b J@5#XP` ,J;2:e`@d$ J$LX,OZ ZfCJZLnLoc`-DV' ALr@:U)H20gF2U\ L( Thank you. Carol, your question falls outside the scope of this article. Also, once the polyp is removed, the follow-up visit should not be coded with K63.5 Polyp of colon, but rather Z86.010 Personal history of colonic polyps. 2vFQEVUDJ]d"&I`yAyb}QK}[-J\E`mkmfCN%c6T=}Gwu?cWm} k?,rv?:luX;q%(+a8gRc1bmZ #w?Q[Zcxo 5f5'q>^n"&8CWpXJ7_e MY/ As you can see, its important to note a patients risk for colorectal cancer, as it will determine how often Medicare will cover a test. 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. Heres what you need to know to correctly code colonoscopies for all four encounter types. Thank you for this article, the diagram is perfect! In most cases, anesthesia is used when performing colonoscopies. 100-04, Medicare Claims Processing Manual, Ch. thank you for any additional information. 3090 0 obj <>stream bOu5/#Y*mrM+iux)dc >d2=)\okND%J9 %PDF-1.6 % Joanne, for help with coding a particular scenario, you may want to post your question in our forums or utilize AAPCs Ask an Expert service. Required fields are marked *. &)y+Cl:Ku]`P-! (Previous screening blood test was negative). Fletcher, TerryA. BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM, Gastroenterology Coding Reference Guide, cdc.gov/cancer/colorectal/basic_info/screening/index.htm, codingintel.com/coding-for-screening-colonoscopy, gastro.org/practice-guidance/reimbursement/coding-faq-screening-colonoscopy, cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventive-services/mps-quickreferencechart-1.html#COLO_CAN. Tech & Innovation in Healthcare eNewsletter, A family history of familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer or a close relative (. Screening flexible sigmoidoscopy once every 48 months or 119 months for average-risk patients who have received a screening colonoscopy in the past 10 years. 3Dp)0BV 5r''+6w]w_U;+PK?n@Ke\SP _7dAOQJ)YU%D-y^qm 3Rnou^HTLga96bpC]C4fnJ592?iEB__? &RvQ$kBeSC7%B~[Y`+ks(%]NR% H3R1_5_o`n`? Screening barium enema once every 48 months for average-risk patients or once every 24 months for high-risk patients. eN>(mE@^l(t1!Bp+7(ic66#XVnu)$ijr/5}crP"VY>Xm'KxvKu~=]c/OQ$SadJ}SS1w\{tv*xwa+'YTCLe>? qm0p8&7yW2.OHJU;fQa;gSXqic*10UGU\ e?fy[b['-7`kY^ZxW+E0C-t)cS8XvJPo^7M ypr+^DC4>H6"xN6$4. Nice recap for those not familiar with GI. Append modifier 33 Preventive service to the procedure code to trigger the preventive benefits (no cost-sharing) to the patient. 2343 0 obj <>stream Colonoscopy is a medical procedure in which the physician inserts a long, flexible, tubular instrument called a colonoscope into the patients anus to examine the lining of the entire colon for abnormalities and disease conditions. Surveillance colonoscopy is when the patient is asymptomatic but has a personal history of gastrointestinal disease, colon polyps, or cancer. Indication: Colon screening on average risk patient, Post-endoscopy findings: Polyps in the cecum and sigmoid colon, Procedure performed: Colonoscopy with removal of cecal and sigmoid polyp by snare technique, Coding: 45385-33, Z12.11, D12.0, D12.5 or K63.5 (non-Medicare), 45385-PT, Z12.11, D12.0, D12.54 or K63.5 (Medicare). Please try posting your question on our forums. N%d0dFX:MHba 5T(jp`4@7!rh. To indicate a screening colonoscopy is for surveillance of a previous problem, be sure to report the applicable history code, provided it is supported in the medical record. Privacy Policy | Terms & Conditions | Contact Us. 54YzU2KCPww)lsp)^B5,O `6:x4h NtfP9m.#g]#c-0/u?v f03g|eD{j( sV`6Jwg!-L,nR IMMaC-S."Vq62\K- This does not waive Medicare patients 20 percent coinsurance and/or a copay, but it will waive the deductible. A traditional medicare insured patient, with a positive cologuard, underwent colonoscopy which resulted in negative findings. 3044 0 obj <> endobj Medicare does not cover a pre-procedure visit for a screening colonoscopy. She is associated with Vitalaxis, Inc., as senior coding manager. Patient age 29, experiencing many GI symptoms including chronic diarrhea, gas, upper GI stomach upset, indigestion etc. For a screening colonoscopy, this service may be reported separately with CPT code 00812 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy (Medicare coinsurance and deductible are also waived). h[$qb&&@ @D@ %a];J>CtrOD|l>hV'^c30TMfeH3ff+oKZHM/X1n"\ookM=_Ko_{/n7?'_7__}2_wgX/}n>Q Cpq#? As of 2022, the majority of commercial insurances cover screening colonoscopy for patients aged 45 and older. Lets look at a few coding examples for various colorectal cancer screening encounters. 60, start the count beginning with the month after the month in which a previous test/procedure was performed. In other words, if the test was performed in March, begin counting from April.