Wiki Colonoscopy questions typically not answered in webinars

[dawnmharrison@verizon.net]

3 Questions:

1) A patient under the age of 45 coming in for a colonoscopy due to a family history of either colon cancer or polyps. I assume this would be payor specific but in general would you use the screening or the history as primary and would you use the 33 modifier? I’ve had claims denied for the use of these on occasion and would appreciate your opinion on how we should handle this situation.



2) The provider completes the colonoscopy but due to poor bowel preparation has the patient come back within a couple of months. I understand the use of 53 for incomplete but technically this is a complete procedure. Would it be advised to use the 53 anyway? It seems lately that the providers are going all the way to the cecum when maybe they shouldn’t knowing the prep is not sufficient. Your thoughts would be truly appreciated.



Positive cologuard tests. I recently heard that some plans may start allowing for the follow-up colonoscopy as preventive. Have you heard anything about this?

 

[nickelclaw]

Hello,

1) only use screening code if documented don't assume. if not on OP but as dx for HP that is ok. hx codes can never be primary dx. As such Z12.11 will always be primary with the hx codes. You are correct that payors have their own rules.
I am a facility coder we don't use 33 on screenings. Use G codes or 45378-PT for screening on some carriers that won't take G codes.
I read in the coder desk reference that 33 may not be used on codes that are inherently preventive codes(screening mammo example)
Whenever a screening becomes a diagnostic (polypectomy) the CPT code must have modifier PT (to state screening turned into diagnostic) example: 45385-PT Snare polypectomy with Z12.11 primary dx

2)correct if to cecum no mod because it was a complete procedure. May let providers know that when they bring them back it won't be able to be billed again as a screening.

I haven't heard. All I know as of now is that the cologuard is the screening test and if comes back abnormal. Then you are coding diagnostic/therapeutic scope. Side note the CT screening colonoscopy would be the same. If CT is abnormal then they have colonoscopy done it would be 45378 etc.. Hope this helps!

 

[mconner001]

Hi,

On question #2 - If the provider is bringing the patient back for a repeat then yes, we use the 53 modifier and put a note in box 19 indicating how far they got and that the prep was inadequate.
Question #3 - Our consulting firm just let us know yesterday that they haven't seen many payers yet come out with instructions/guidelines regarding this. They explained that this would be a diagnostic colonoscopy that would process under the preventative benefits and that we should add the 33 modifier. Hoping that more information becomes available as to how they want this to work!

 

[nsteinhauser]

On question #3:
From "FAQs about Affordable Care Act Implementation Part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation"

Q8: When must plans and issuers begin providing coverage without cost sharing for a
follow-up colonoscopy after a positive non-invasive stool-based screening test or direct
visualization test based on the new USPSTF recommendation?
Plans and issuers must provide coverage without cost sharing consistent with the May 18, 2021
USPSTF recommendation regarding colorectal cancer screening and in accordance with the
requirements under PHS Act section 2713 for plan years (in the individual market, policy years)
beginning on or after the date that is one year after the date the recommendation was issued. In
this case, the recommendation is considered to have been issued as of May 31, 2021, so plans
and issuers must provide coverage without cost sharing for plan or policy years beginning on or
after May 31, 2022.32

We've reached out to payers and haven't heard anything. Sounds like eff. 05/31/22, a colonoscopy following a positive Cologuard* will then still be considered a screening vs. a diagnostic.
Hope this helps.