Consider All Factors when Coding Colonoscopies
By Sarah W. Sebikari, MHA, CPC
Colorectal cancer is the second leading cause of death in the United States. According to the American Cancer Society, if all adults 50 and older were screened for colon cancer, we could cut the death rate from this disease in half, saving approximately 25,000 lives each year.
Colonoscopy is considered the gold standard of screening for colorectal cancer. Coding for colorectal cancer screening is complicated by several factors, including findings, patient personal and family history of gastrointestinal cancer, how far the scope was advanced, and therapeutic versus diagnostic procedures. In addition, the following factors should be considered when coding colonoscopies:
- Procedures performed
- Technique used
- Instruments used
CPT® 2012 defines a colonoscopy as an exam of the entire colon from the rectum to the cecum, and may include the examination of the terminal ileum. The colon includes the rectum, sigmoid colon, descending colon, splenic flexure, transverse colon, ascending colon and cecum. Knowing your anatomy will assist you with proper coding.
A diagnostic colonoscopy allows the physician to visualize the colon for any abnormalities or to establish a diagnosis. The patient may exhibit symptoms such as diarrhea, blood in stool, abdominal pain, etc. Risk factors also play an important role in diagnosis coding.
Example 1: Patient has change in bowel habits, abdominal pain, and diarrhea for the past two weeks. Colonoscopy is recommended. The scope is passed through the anal verge to the sigmoid colon where inflammation is noted. Multiple biopsies of the sigmoid are taken. Further advancement of scope to the cecum confirms a normal column. The scope is withdrawn.
- 789.00 Abdominal pain, unspecified site
- 787.99 Other symptoms involving digestive system (change in bowel habits)
- 787.91 Diarrhea not otherwise specified (NOS)
- 558.9 Other and unspecified noninfectious gastroenteritis and colitis (inflammation of sigmoid colon)
Procedure code: 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
Rationale: When coding, diagnosis symptoms are sequenced first, and findings last. Because multiple biopsies were taken to determine the cause of symptoms, a surgical colonoscopy is appropriate.
Screening is performed in the absence of symptoms. The patient may be high risk (e.g., family history of colon cancer, diagnosis code V16.0 Family history of malignant neoplasm of gastrointestinal tract) or “of age.” When no symptoms are present, use V76.51 Special screening for malignant neoplasms of colon as the primary diagnosis.
Example 2: Colonoscopy is performed to rule out any abnormalities, such as polyps, on a 50-year-old patient with a family history of colon cancer. Scope was passed under direct visualization. Colonoscopy was performed without difficulty. Patient tolerated the procedure well (bowel prep quality was excellent). The entire colon appeared normal. No polyp tissue was seen. The terminal ileum, retroflexed view of distal rectum, and anal verge all appeared normal.
Procedure code: 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
Rationale: Because the patient is high-risk, screening colonoscopy is performed to rule out any disease. In the absence of findings, diagnostic procedure code 45378 represents the service performed.
Therapeutic colonoscopy (45355-45392) occurs when abnormalities (often found during a screening) are treated. During therapeutic procedures, lesion or polyps maybe removed for biopsy via polypectomy, laser removal, or cauterization. Designating a colonoscopy as “diagnostic” versus “therapeutic” is usually done after the procedure is performed.
Example 3: A 55-year-old patient with no prior history of colonoscopy undergoes a screening colonoscopy. Findings: Large polyp in the cecum removed/biopsied with cold forceps. Another polyp located at 65 cm is injected with India ink and biopsied with snare. Diverticulitis in sigmoid colon is also noted.
- 211.3 Benign neoplasm of colon
- 562.11 Diverticulitis of colon (without mention of hemorrhage) (diverticulitis sigmoid colon)
45380, 45385-59 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45381-59 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
Rationale: Although the patient is seen for screening colonoscopy, findings indicate polyps removed by polypectomy. CPT® coding in this case is driven by the findings. Also, per CPT® guidelines, surgical endoscopy always includes diagnostic endoscopy. Modifier 59 Distinct procedural service is appended to secondary procedures to indicate that they are distinct.
Per the Centers for Medicare & Medicaid Services (CMS), the multiple-procedure rule applies to secondary procedures. In other words, if two or more procedures are performed during the same session, the highest paying would be billed at 100 percent of the fee schedule rate, and any other (non-add-on) codes would be paid at 50 percent of the fee schedule rate. Check with specific carriers, as this rule may differ across carriers.
Reporting Colonoscopies to Medicare
For Medicare patients, you should report HCPCS Level II codes for screening colonoscopy:
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
Per CMS guidelines, a patient is considered high risk if he or she meets one of the following criteria:
- A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
- Family history of familial adenomatous polyposis
- Family history of hereditary non-polyposis colorectal cancer
- Personal history of adenomatous polyps
- Personal history of colorectal cancer
- Personal history of inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
Colorectal cancer screening for a Medicare patient may be reported with the following HCPCS Level II codes:
G0104 Colorectal cancer screening; flexible sigmoidoscopy
G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
Example 4: Colonoscopy was performed to rule out any abnormalities, such as polyps, on a 65-year-old patient with personal history of colon polyps. Scope was passed under direct visualization. Colonoscopy performed without difficulty. Patient tolerated the procedure well. The entire colon up to the terminal ileum appeared normal.
- V12.72 Personal history of colonic polyps
Rationale: The patient is considered high risk per Medicare guidelines because he has a history of colon polyps, making G0105 the appropriate screening code.
If findings are positive for additional polyps, CPT® codes 45380-45392 may be reported for Medicare. Consideration would be given to the technique used to remove the polyp to appropriately code the procedure (see example 3).
Sarah W. Sebikari, MHA, CPC, is senior coding analyst with Premier Health Care Exchange, a health care cost management company. She has been in the health care field for the past 11 years and a certified coder for the past nine years, with experience spanning from multiple-specialty physician to outpatient coding and reimbursement.
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