General Surgery Coding Alert

V code diagnoses provide justification for screening exams

When choosing a code for a screening colonoscopy that becomes "diagnostic" by the end of the patient encounter, you should stick with 45380, coding experts say. Medicare Requires Screening G Codes For Medicare patients, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for an average-risk patient receiving a screening colonoscopy, or G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for a high-risk patient, says Julia Covington, billing/collections office manager for Karen L. Woods, MD, in Houston.

Tip: Follow Medicare's diagnosis-code lead and cite V codes when reporting high-risk screening colonoscopies (G0105). Some diagnoses that Medicare considers high-risk factors for colorectal cancer, and therefore justify screening colonoscopies, include:

V10.05 -Personal history of malignant neoplasm; gastrointestinal tract; large intestine

V12.72 - Personal history of certain other diseases; diseases of digestive system; colonic polyps

V16.0 - Family history of malignant neoplasm; gastrointestinal tract

V18.5 - Family history of certain other specific conditions; digestive disorders

555.0 - Regional enteritis of small intestine. Polyp Transforms Screening to Diagnostic When the surgeon performs a diagnostic, non-screening colonoscopy, you should turn away from the G codes. But what if the colonoscopy begins as a screening and ends up diagnostic?

Question: The surgeon begins a screening colonoscopy for an average-risk Medicare patient. She then finds a polyp, which she biopsies. In this scenario, which of the following code(s) choices would you use to describe the encounter?
CPT 45380 - Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple

G0121

G0121 and 45380 with modifier -59 (Distinct procedural service) attached.

Leave G Code Off Screening Claim You should choose 45380 alone, without any modifiers, when a screening exam becomes diagnostic, according to two experts.

Expert 1: "I would report just 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)," Covington says.

Expert 2: "If during the screening colonoscopy, the surgeon detects a lesion or growth that results in a biopsy or removal of the growth, you should bill, and be paid for, the appropriate diagnostic procedure [45380] rather than code G0121," says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers. Some Private Payers May Use G Codes If your surgeon 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.

When coding screenings for non-Medicare patients, you can stick with 45378 whether the [...]