Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed screening colonoscopy for a Medicare patient in our office due to family history of colon cancer. The patient has no signs and symptoms and also does not have a personal history of any gastrointestinal problems. During the colonoscopy, our gastroenterologist found a polyp in the ascending colon. He then proceeded to remove the same using snare technique. Do I use screening codes or diagnostic codes to report the procedure? Also, please do let me know the ICD-9 codes that I need to report?

Cincinnati Subscriber

Answer: Medicare provides coverage for screening colonoscopy performed to check for the presence of polyps or cancer in the colon. The interval between periodic checks (surveillance colonoscopies) is determined depending on the findings during an initial screening colonoscopy and the patient’s family history risks.

For a patient with high risk, you will have to report the colonoscopy with G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). High risk criteria include a personal history of colon polyps or colon cancer, a family history of colon polyps or cancer, and different forms of chronic inflammatory bowel disease. But when screening is performed on patient not meeting the criteria suggestive of high risk, you will have to report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk). The accepted interval for screening colonoscopy is ten years in patients not meeting criteria of high risk.  If the patient with high risk has undergone a surveillance examination at an interval of 5 years and no polyps were found during the colonoscopy, you should report G0105.

However, since your gastroenterologist found a polyp during the screening, you cannot report G0105 or G0121. Instead, you should report the therapeutic procedural code that your gastroenterologist performed to eliminate the polyp that was found. As your gastroenterologist removed the polyp using snare technique, you will have to report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) instead of the screening HCPCS code. You should also add the PT modifier (Colorectal cancer screening test; converted to diagnostic test or other procedure) to the CPT^® code to tell the CMS contractor that this was a “screening” exam turned therapeutic.  Similarly you would use modifier 33 (Preventive services) if patient was under a commercial plan and the procedure was initially scheduled as routine screening.

You will have to use the V codes V76.51 (Special screening for malignant neoplasms colon) if this was the patient’s initial screening examination, and V16.0 (Family history of malignant neoplasm of gastrointestinal tract) to support the medical necessity of conducting the colorectal cancer screening for the patient. The ICD-9 code for the removed colon polyp is 211.3 (Benign neoplasm of colon).