Gastroenterology Coding Alert
All Non-Medicare Screening Colonoscopies Are Not Created Equal
Some private payers may prefer G codes for the test When a Medicare or private-pay patient reports to your office for a screening colonoscopy to check for colorectal cancer, you'll need to know how to report a colonoscopy that starts out as a screening but is diagnostic by the end of the encounter. Coding Screenings Can Get Complex But screening colonoscopies aren't just for Medicare patients, so you'll also need to learn the rules for reporting the procedure to private payers - and it can get more complicated than you may think. (Did you know that some private payers would rather see Medicare G codes than CPT Codes on your claims for colorectal cancer screenings?) Polyp Pushes Screening Colonoscopy to Diagnostic Before reading on, see how your coding expertise stacks up with a couple of experts. Try to answer the following real-life coding question, then read on for the experts' responses. Experts Agree: Leave G Code off of This Claim We put this very question to a pair of seasoned coders, and here's what they had to say. Some Private Payers May Use G Codes If your gastro performs a screening colonoscopy on a non-Medicare patient, you should report 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]), Covington says. If your non-Medicare patient has one of these diagnoses, you might want to consider including it on your 45378 claim.
Knowing the basics of Medicare reporting for screenings is a must, and most gastroenterolgy coders are quite familiar with the coding choices.
The basics: Coders report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for an average-risk Medicare screening colonoscopy, while G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) is for high-risk Medicare patients, says Julia Covington, billing/collections office manager for Karen L. Woods, MD, in Houston.
Keep reading for pointers on when to use G codes to report screening colonoscopies, when to use CPT codes, and when the best option is to call and ask a carrier rep.
Test your knowledge: Let's say your gastro starts performing a screening colonoscopy for an average-risk Medicare patient. She then sees a polyp, which she biopsies.
In this scenario, what should you report?:
Expert 1: "I would report code 45380," Covington says.
Explanation: "Once the polyp is visualized and biopsy performed, the diagnosis would have to change from V76.51 (Special screening for malignant neoplasms; colon) to 211.3 (Benign neoplasm of other parts of digestive system; colon)," she says.
Expert 2: "If during the course of the screening colonoscopy, a lesion or growth is detected that results in a biopsy or removal of the growth, the appropriate diagnostic procedure [45380] should be billed and paid rather than code G0121," says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers.
Best advice: Follow the experts' lead and report CPT 45380 when a gastro biopsies a polyp on a Medicare patient during an average-risk screening colonoscopy.
When coding screenings for non-Medicare patients, report 45378 whether the patient is at high or low risk for colorectal cancer. With private payers, the risk category is not as vital as when reporting with Medicare.
Exception: Pfaff says she uses 45378 for a simple screening for all non-Medicare patients - "unless there is a contract with a payer that states that they [the payer] utilize Medicare G codes. If there is not a contract, report the CPT code as 45378 and an appropriate screening ICD-9 code [V76.51], since many insurances have preventive benefits," she says.
Hot Tip: Follow Medicare's diagnosis-code lead when reporting high-risk screening colonoscopies (G0105). Some of the diagnoses that Medicare considers high-risk factors for colorectal cancer - and therefore justify screening colonoscopies - include:
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