Screening Colonoscopy: Coding without the Stigma

Decipher how to code this life-saving benefit for Medicare and private payers.

By Jenny Berkshire, CPC, CEMC, CGIC

Katie Couric had a screening colonoscopy on live television. Former President George W. Bush had one. Even the newspaper comics are talking about screening colonoscopy. And it’s no wonder; screening colonoscopy is a life-saving procedure that can prevent and detect colorectal cancer (CRC).

CRC is the second leading cause of cancer death in this country and the third most common type of cancer. CRC primarily affects men and women over 50 years of age and the incidence increases with age. It is highly curable with early detection.

There are alternatives to screening colonoscopy included in the Centers for Medicare & Medicaid Services (CMS) CRC benefits (flexible sigmoidoscopy, barium enema, and fecal occult blood tests), but colonoscopy has become the gold standard for colorectal cancer screening. Medicare first provided benefits for CRC screening in 1998 and expanded the benefit in 2001. It is the most comprehensive screening benefit Medicare provides, but less than 50 percent of eligible beneficiaries are taking advantage of this live-saving benefit, according to CMS.

It seems that CRC screening carries a stigma for being unpleasant—for both patients and coders.Many physicians of various specialties provide this service, but how it’s billed to Medicare and commercial insurance carriers can be difficult to decipher. As a gastroenterology coding and compliance consultant, I address the coding differences in many practices, and I see questions regarding these differences posted repeatedly on the AAPC Medical Coding & Billing Forum.

Medicare Coverage

CMS pays for the screening colonoscopy for high-risk patients and for average-risk patients. Age, frequency, and diagnosis details are defined by CMS in the Medicare Claims Processing Manual, chapter 18, section 60.

Patients at average-risk for CRC—those without signs, symptoms, past family or personal history of colon cancer, or a past history of adenomatous colon polyps—are eligible for a screening colonoscopy once every 10 years, beginning at age 50. The HCPCS Level II billing code for the screening colonoscopy for average-risk patients is G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk. The appropriate diagnosis codes describing average-risk are listed in the Medicare Claims Processing Manual at the site listed above in section 60.3.

Patients at high-risk for CRC are eligible for a screening colonoscopy every two years with no minimum age requirements. The HCPCS Level II billing code for the screening high-risk colonoscopy is G0105 Colorectal cancer screening; colonoscopy on individual at high risk. The diagnosis codes describing the patient’s high-risk are also listed in the Medicare Claims Processing Manual, section 60.3.

CMS provided an expansion to the screening colonoscopy benefit in 2007 by waiving Medicare’s yearly deductible. Coinsurance is due from the patient for the screening colonoscopy provided in an ambulatory service center (ASC) or outpatient setting; however, coinsurance is 25 percent rather than the usual 20 percent. The fee allowance for screening colonoscopy is comparable to diagnostic colonoscopy reimbursement.

When a screening colonoscopy is attempted, but not completed (the usual reason is a poorly prepped patient), the physician may bill Medicare for an incomplete exam using modifier 53 Discontinued procedure. The modifier indicates the screening exam was not complete and may be repeated at a later date. Using the modifier ensures both procedures will be paid without regard to the frequency restrictions.

Note that payers who follow CPT® rules require modifier 52 Reduced services, not modifier 53, for an incomplete colonoscopy.

A common occurrence during screening colonoscopy is finding a polyp or lesion requiring intervention by the physician. CMS addresses this situation in a MLN Matters number SE0746 and instructs coders to bill with the appropriate CPT® intervention code and to list the screening diagnosis code first, followed by the diagnosis code required for the intervention. On the claim form, insert the number 2 in box 24E (the diagnosis pointer field) to link the diagnostic procedure with the second reported diagnosis code (the abnormal finding diagnosis code requiring the intervention).

Many Medicare Administrative Contractors (MACs) have Local Coverage Determinations (LCDs) addressing screening colonoscopy. It is important to know if your MAC has an LCD and to be aware of its language. There can be subtle instructions in the LCD which should be followed when billing the CRC screening exam.

A common question I address with the CRC screening is about the frequency restriction when a patient undergoes a colonoscopy, presenting with signs or symptoms before the patient is eligible for a screening colonoscopy. The return procedure would not be screening; the patient is presenting with signs and/or symptoms, and is not subject to frequency limitations. Frequency limitations for screening benefits are applied from one screening or G code to the next screening G code.

An Advance Beneficiary Notice (ABN) may be an appropriate tool to use when providing the screening colonoscopy. If a patient has undergone a screening colonoscopy with another provider, and your physician provides the service prior to the frequency limitations, your screening colonoscopy would be denied and not billable to the patient unless the ABN is on file. Obtain the ABN prior to the time the patient presents for the exam already prepared. The preparation for colonoscopy can be difficult to complete, and asking the patient to sign the ABN after prep, at the time of the exam, might influence your patient’s desire to delay the procedure. When the ABN is on file, you may bill the service with modifier GA Waiver of liability statement on file.

Commercial Payers

Commercial insurance has different coverage, definitions, and coding requirements for screening colonoscopy. Many insurers, particularly those offering health spending accounts (HSAs) provide better benefits for preventive services, including screening colonoscopy, so it’s important to develop policies addressing the issues defined in CMS’ benefit description for CRC screening procedures. A good practice is to implement CMS’ policy across the board for all payers, and to inform and educate patients before they are scheduled for the exam.

Jenny Berkshire, CPC, CEMC, CGIC, has worked for 35 years in medical practices with 28 years in a gastroenterology (GI) practice. Jenny is currently the compliance manager at Wright State Physicians, a university-based, multi-specialty academic medicine practice in Ohio. She is a GI coding and compliance consultant and has taught coding seminars and has spoken at national specialty conventions and GI-specialty conferences.


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