Keep up with ASC Colonoscopy Clarifications
Constant changes in colonoscopy guidelines make it essential to stay current with new reporting requirements.
By Denis Rodriguez, CPC
In the past few years, there have been adjustments in the way colonoscopies are reported in the ambulatory surgery center (ASC), as well as clarifications for the intent of individual codes. Proper payment for this outpatient service requires a thorough examination of Medicare and payer guidelines.
Note: Some of the information that follows also applies to physician coding as well as to ASC facility coding of these procedures.
Reporting Discontinued and Canceled Colonoscopies
Because a colonoscopy is considered complete when the endoscope is passed proximal to the splenic flexure, it’s necessary to become familiar with the different parts of the colon. As shown in Figure A, from distal to proximal, the anatomy includes the anus, rectum, sigmoid colon, descending colon, splenic flexure, transverse colon, hepatic flexure, ascending colon, cecum, and the ileocecal valve, which forms the junction of the large and small intestines (i.e., at the cecum and ileum, respectively).
When the colonoscope is not documented as advanced at least into the transverse colon, append modifier 74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia for an incomplete colonoscopy when performed at an ASC. The operative report must state why and when the procedure was discontinued. The extent and/or percentage to which the procedure was performed also should be documented.
When the procedure is canceled prior to the insertion of the colonoscope, append modifier 73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia to the procedure code.
To support this modifier, the patient chart must document the following:
- Why and when the procedure was canceled
- The patient was taken to the room where the colonoscopy was to be performed
- Anesthesia/sedation was not administered, and the colonoscope was not inserted
Concern for the patient’s well being must be the reason why the procedure was canceled. If the procedure was canceled or rescheduled for the convenience of the patient, physician, or facility, the procedure is not reportable.
Example 1: A patient is prepped and taken to the endoscopy suite for colonoscopy. Prior to the ad-ministration of conscious sedation, the patient becomes hypotensive. The procedure is ab-orted and attempts to stabilize the patient’s blood pressure commence.
This would be reported 45378-73 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).
Example 2: The patient is prepped and taken to the endoscopy suite. Conscious sedation is administered. Prior to the insertion of the colonoscope, the patient becomes hypoxic. The procedure is discontinued and the patient is treated for respiratory depression.
Proper coding is 45378-74.
Differentiate Screening and Diagnostic Colonoscopies
According to the January 2011 issue of the American Gastroenterological Association’s (AGA) GI Quality and Practice Management News, if a patient acknowledges any symptoms when scheduling the colonoscopy, he or she should be informed that the procedure is diagnostic and not screening in nature. If a diagnosis is confirmed in relation to the procedure, billing the procedure to federal payers as a screening colonoscopy would constitute a false claim, or possibly a violation of the contract when billed to a private payer.
The situation becomes less clear when the patient or referring physician does not report any symptoms when scheduling the procedure, but the patient reports past symptoms to the endoscopist when presenting for the procedure. According to the AGA, the endoscopist will have to make a clinical decision as to whether the symptoms warrant a diagnostic procedure, or whether the symptoms are insignificant enough for the procedure to remain a screening. If a screening colonoscopy lists gastroenterological symptoms in the indications section of the report along with the need for screening, the endoscopist should be asked about the clinical significance of these symptoms.
Gastroenterologists will often refer to a “surveillance colonoscopy” when a patient has a history of colon polyps or cancer with no current symptoms. According to the AGA, these colonoscopies are considered high-risk screening procedures.
Per Medicare Learning Network (MLN) Matters, MM7012, for Medicare, you should append modifier PT Colorectal screening test converted to diagnostic test or other procedure to the primary therapeutic colonoscopy code when a screening colonoscopy is converted to a therapeutic colonoscopy. When the screening colonoscopy G codes (G0105 Colorectal cancer screening; colonoscopy on individual at high risk, G0121 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema) are reported, there is no need for the PT modifier.
For private payers, append modifier 33 Preventive service to the colonoscopy code for all screening colonoscopies, whether a therapeutic procedure was performed or not. This is because code 45378 is not inherently a screening procedure, according to CPT® Assistant, “New CPT Modifier for Preventive Service,” December 2010.
Example 3: A Medicare patient presents for a screening colonoscopy. During the colonoscopy the en-doscopist finds pedunculated polyps in the transverse and descending colon that are re-moved by hot snare.
Report 45385-PT Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
Example 4: A Medicare patient at average risk for colon cancer presents for a screening colonoscopy. Visualization to the ileocecal valve reveals only scattered sigmoid diverticuli. No therapeutic procedure is performed.
Report G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk. Modifier PT is not appended because G0121 is inherently for screening.
Example 5: A patient at high risk for colon cancer with commercial insurance presents for a screening colonoscopy. Colonoscopy to the cecum is performed, which reveals no pathology except for small internal hemorrhoids.
Report 45378-33. Although a therapeutic procedure is not performed, 45378 is not inherently a screening code.
Identify Colonoscopic Techniques
During endoscopy, when multiple techniques are used on different lesions, the procedure report should clearly and specifically state: (1) the technique used; (2) the type of lesion; and (3) location of the lesion. Per American Medical Association (AMA) guidelines (see CPT® Assistant, June 2010), each code representing an endoscopic technique(s) should be reported only once, regardless of the number of sites treated with the technique(s).
Example 6: A colonoscopy is performed to the cecum. Pedunculated polyps in the transverse and des-cending colon are removed via hot snare; a hyperplastic rectal polyp is biopsied with cold forceps.
In this case, although two polyps are removed with snare, 45385 is reported only once. Be-cause the endoscopist clearly identified the location of the third lesion, we can identify it as a different lesion and code the different technique used to treat it (i.e., biopsy) separately with 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. Append modifier 59 Distinct procedural service to the bundled colonoscopy procedure code when a different lesion is clearly identified.
Note that 45385 is for colonoscopy with removal of a lesion by snare. When the snare tip is used to ablate the lesion, rather than remove it, the AMA has stated (via CPT® Network’s Knowledge Base, July 2010) that unlisted code 45999 Unlisted procedure, rectum is appropriate. You may report 45385 for hot, cold, monopolar, and bipolar snare techniques.
According to the January 2004 CPT® Assistant, “Remnants of the lesion after use of a snare can be cauterized or ablated to completely destroy the intended target but only one technique should be reported to remove a unique polyp or lesion.” In this scenario, because ablation represents definitive treatment of the lesion, you should report 45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other le-sion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique; 45385 would not be separately reported.
Do Not Report Control of Bleeding
When bleeding is a result of a therapeutic intervention, control of that bleeding is consi-dered part of the therapeutic procedure and should not be separately reported.
According to April 2012 CPT® Assistant, active bleeding does not need to be documented to use the endoscopic control of bleeding codes. When lesions such as angiodysplasia of the intestine are associated with chronic intermittent bleeding that is not specified as active during the procedure, their ablation may be considered control of bleeding.
Example 7: A colonoscopy is performed to the cecum. Two polyps are seen in the descending colon, both of which are cold snared. The base of one of the lesions starts to hemorrhage; this is cauterized, achieving hemostasis.
The proper coding is 45385. The hemorrhage is due to snare polypectomy, and therefore its control is not separately reported.
Coding for colonoscopies can be challenging given the constantly changing reporting and coding guidelines. Keeping abreast of these changes will help you remain a valuable asset to your organization.
Denis Rodriguez, CPC, is senior ambulatory surgery center coder and compliance auditor for The Coding Network, LLC. He has more than 24 years experience in the medical field, the last 11 of which have been spent exclusively in ASC coding, auditing, and education.