Excellent tips for Screening Colonoscopy CPT Code

Screening Colonoscopy cpt code
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Colonoscopy coding depends on exactly what the physician does, as well as the method he uses.
If the physician performs polypectomy: Find out how she removed the polyp (biopsy or snare). In the case of multiple polyp removal, determine where on the colon each polyp was located and whether the polyps were in separate locations or close enough to be considered one location. Next, you should check the method by which the surgeon removed each polyp.


To help you through ambiguous chart documentation, remember these code/procedure descriptions:
0 -- Cold Biopsy Forceps. These are disposable forceps that take tissue samples during an endoscopy. No electric current passes through them -- thus, the term "cold."
You cannot use these forceps to cauterize bleeding that the forceps may cause. A partial polypectomy is usually a cold biopsy, whereas a total or entire procedure is done with a snare (45385), which lassoes the polyp.
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Exception: On occasion, the physician will perform a polypectomy in an area of the bowel where there is not a great blood supply, such as the lower anal canal. In this case, she does the polypectomy with cold biopsy forceps (because any bleeding is not significant), and you should bill this procedure using 45380 (even though it is a polypectomy and not a biopsy).

1 -- With Directed Submucosal Injections. The "substance" described by 45381 (Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection[s], any substance) could be saline, India ink, methylene blue, Botox, or steroids.

2 -- Control of Bleeding. Physicians may use many of the same techniques for cauterization (to control bleeding) that they use for ablation -- and the code definition can also be confusing. But the defining factor is the diagnosis. For example, use 45382 (... with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) when the surgeon controls bleeding from a polyp removed several days ago or for diverticulosis (562.12, Diverticulosis of colon with hemorrhage) or diverticulitis (562.13, Diverticulitis of colon with hemorrhage). Another application is for angiodysplasia (569.85, Angiodysplasia of intestine with hemorrhage).

Important: You cannot separately bill 45382 if the physician caused the bleeding during the colonoscopy.

3 -- Ablation. An ablation, normally performed during a follow-up colonoscopy, usually refers to a cauterization performed with an argon plasma coagulator (APC), heater probe, or other device that destroys any remaining polyp cells after a prior colonoscopy during which the surgeon removed a larger polyp using a snare.

When using any of these methods either for an ablation or to control bleeding, use 45383 (... with ablation of tumor[s], polyp[s], or other lesions[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

Be careful: You shouldn't apply 45383 when the doctor uses hot biopsy forceps, bipolar cautery, or snare technique for the ablation.

4 -- Hot Biopsy Forceps or Bipolar Cautery. When the physician both removes and cauterizes a polyp simultaneously using hot biopsy forceps, you should use 45384 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). Normally, these are smaller polyps. Also apply this code for bipolar cautery.

5--- 45385 -- Snare Technique. Usually, surgeons remove polyps -- especially larger ones -- during a colonoscopy with the snare technique, which employs an electrocautery snare (a heated wire loop that shaves off the polyp).

In this situation, use 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). Physicians could theoretically also use these snares, also called "hot snares," for cautery, but that's unusual. A snare has cautery on it, but you're not ablating the polyp.

Adhere to Bundling and Modifier Policies

If you're going to bill 45384 or 45385, remember that the Correct Coding Initiative (CCI) bundles 45380 into both of them.

Under certain circumstances, however, you can code both the biopsy and the polypectomy if you append modifier 59 (Distinct procedural service) to the lesser-valued code. By overcoming the edit in these cases, you can legitimately increase your reimbursement.

Example 1: If the physician performs a biopsy at one site (45380) and removes a polyp at another site with a cold snare technique (45385), you would list 45385 first and append modifier 59 to 45380.

Example 2: The physician takes a biopsy at one site (45380) and removes a polyp at another site with hot biopsy forceps (45384). In this case, report 45384 first, followed by 45380 with modifier 59 appended. The 59 modifier indicates to the payer that the surgeon performed the procedures at different locations.

Follow Billing Frequency Rules

To avoid denials, make sure you bill 45380 only once during a colonoscopy -- regardless of how many biopsies the surgeon performs. This applies even if the physician takes biopsies at several different locations (for instance, the transverse and descending colon).

You can also bill 45381 only once per session, even though the physician may administer multiple injections during the procedure.

Likewise, no matter how many tumors, polyps, or lesions the doctor treats by the same or similar techniques, remember that the words "tumor(s), polyp(s), or other lesion(s)" in the descriptions of 45383, 45384, and 45385 signal that you're also restricted to reporting only one of these codes per colonoscopy.
When the surgeon uses different techniques, however, you can bill multiple tumor, polyp, or lesion removals, as long as you report each code only once per technique.

Example: The surgeon uses hot biopsy forceps and the snare technique to remove polyps during a single colonoscopy. As long as documentation supports the need for using two different techniques on two different polyps, you should report both 45384 and 45385, with modifier -59 appended to code 45384.

Screening vs. Diagnostic Colonoscopy

When choosing a code for a screening colonoscopy that becomes "diagnostic" by the end of the patient encounter, skip Medicare's screening codes and stick with 45380.

For Medicare patients, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for an average-risk patient receiving a screening colonoscopy, or G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for a high-risk patient.

Tip: Follow Medicare's diagnosis code lead and cite V codes when reporting high-risk screening colonoscopies (G0105). Some diagnoses that Medicare considers high-risk factors for colorectal cancer, and therefore justify screening colonoscopies, include:

·         V10.05 -- Personal history of malignant neoplasm; gastrointestinal tract; large intestine

·         V12.72 -- Personal history of certain other diseases; diseases of digestive system; colonic polyps
V16.0 -- Family history of malignant neoplasm; gastrointestinal tract
V18.5x -- Family history of certain other specific conditions; digestive disorders...
555.0 -- Regional enteritis of small intestine.


Polyp Transforms Screening to Diagnostic

When the surgeon performs a diagnostic, non-screening colonoscopy, you should turn away from the G codes. But what if the colonoscopy begins as a screening and ends up diagnostic?
Example: The physician begins a screening colonoscopy for an average-risk Medicare patient. She then finds a polyp, which she biopsies.

In this scenario, you should choose 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple), without any modifiers, rather than G0121.

In other words: If during the screening colonoscopy the physician detects a lesion or growth that results in a biopsy or removal of the growth, you should bill -- and be paid for -- the appropriate diagnostic procedure (45380) rather than G0121.

Screening-Turned-Diagnostic Dx Coding Less Certain

For an average-risk Medicare patient, you would assign a diagnosis of V76.51 (Special screening for malignant neoplasms; colon) for a screening colonoscopy (G0121). For a high-risk patient (G0105), you could assign a high-risk diagnosis, such as those listed above.

Problem: Assigning a diagnosis for a screening colonoscopy that becomes diagnostic, however, is more difficult. CMS has not provided clear guidance on this point, and Medicare carriers differ in their opinions.

Background: In February 2006, CMS officials stated that when a screening colonoscopy finds a polyp, you should bill using the polyp diagnosis (for instance, 211.3, Benign neoplasm of other parts of digestive system; colon), not the screening V code.

The policy is that if you find a polyp and remove it, you change to the diagnostic code. But you can still use the V code diagnosis (secondary to the polyp diagnosis) to indicate that the colonoscopy began as a screening colonoscopy.

The retraction: Several months later, CMS officials distanced themselves from the earlier instruction, pointing to language in the ICD-9 diagnosis coding guidelines that state that you should still use the screening diagnosis even if you find a problem during a screening exam: "Should a condition be discovered during the screening, then the code for the condition may be assigned as an additional diagnosis," according to ICD-9 instructions.

Ask Your Payer for Guidance

Most Medicare carriers favor using a polyp diagnosis (rather than a V code) for the primary diagnosis if the physician finds a polyp during a screening. The January 2004 CPT Assistant (published by the AMA) also came down on the side of putting the polyp diagnosis first when the physician finds a polyp and performs a therapeutic procedure.

Not everyone agrees: A few Medicare carriers, however, have come down on the side of keeping the V code even if you find a polyp during a screening.

Bottom line: There is no consensus on whether you should use a polyp diagnosis or the V code as primary when the physician finds a polyp during a screening exam. For now, you should follow your carrier guidelines -- whatever they may be. If your carrier tells you to list the polyp diagnosis first, go ahead and do that.

But with so many conflicting opinions circulating, you'll want to be sure to get the carrier's instruction in writing. That way, you're covered no matter what happens in the future.

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15 November 2014 at 06:36 delete

You make a great point. Got some great information here. I think that if more people thought about it that way, theyd have a better time understanding the issue. Your view is definitely something Id like to see more of. Thanks for this blog. Its fantastic and so is what youve got to say.

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18 January 2015 at 04:56 delete

thanks for such kind words on my article on cpt code for screening colonoscopy....keep visiting and sharing your thoughts in comment box

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