General Surgery Coding Alert

Even veteran general surgery coders struggle with the challenge of properly coding a screening-turned-diagnostic colonoscopy. Plus, if you aren't aware of the diagnosis coding pitfalls involved in colonoscopy coding, your job becomes even more difficult.

Good news: If you remember a few key points you'll be sure to pick the correct procedure and diagnosis codes every time.

If your surgeon performs a screening colonoscopy for a Medicare patient, choose between two G codes: 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.

You'll use these G codes "when the doctor is performing strictly a screening colonoscopy," emphasizes Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio. "These codes also include any pre-scope office visit, so you cannot bill an E/M code when these codes are used."

Dx help: If the surgeon's documentation states that the patient presented for screening colonoscopy, you will use the screening V code (such as V76.51, Special screening for malignant neoplasms; colon) as the first ICD-9 code, Lamm says. If you're reporting G0105, be sure you also attach a secondary diagnosis code that will support the fact that the patient is high-risk. For example, you might also use 555.0 (Regional enteritis; small intestine) and/or V16.0 (Family history of malignant neoplasm; gastrointestinal tract). (Stay tuned to future issues of General Surgery Coding Alert to learn how you should determine whether the patient is truly high-risk, warranting G0105.)

Keep in mind: Private payers have their own rules, so you have to know how they want you to report a screening colonoscopy. "Many of them follow Medicare's lead; however, there can be differences in the diagnosis code they want, or their method for reporting a change from screening to diagnostic," Lamm points out. "Coders should have the rules for each payer on hand for reference." Change Your Coding When Doc Discovers Polyp When the surgeon finds and treats a problem, you can no longer report the G code for the screening colonoscopy.Instead, you will use a Category I CPT code, based on the treatment or technique the surgeon uses to biopsy and remove the polyp. "Any polypectomy or biopsy changes the CPT code for the colonoscopy," Lamm says. "This ensures that you are most accurately reporting the services that were rendered."

Scenario: During a screening colonoscopy for an average-risk Medicare patient, the physician discovers several polyps. He removes the polyps during the same procedure using a snare technique. In this case, you should report the colonoscopy with polyp removal via snare technique (such as 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s], by snare technique).

Watch out: Just because your surgeon started out performing a screening colonoscopy and then ended up also treating a polyp, that doesn't mean you can report both a screening procedure code and a diagnostic procedure code. You should report only the diagnostic procedure code, without any modifiers.

When a colonoscopy goes from screening to diagnosis, you may be tempted to skip the screening V code and just report the polyp diagnosis. Think again. You should still use the screening V code as the primary diagnosis, even if your surgeon finds a polyp and performs a diagnostic colonoscopy during the screening exam. CMS has offered very specific direction, about what to do if there is a growth or lesion detected during a screening exam, said Jill Young, CPC, CEDC, CIMC, in the Elisponsored audioconference "Managing Colonoscopies:Smart Practice Management in a Tough Economy."

Medicare published an article answering that question.

"Whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination," states Medicare Learning Network (MLN) Matters article SE0746

You should report the polyp diagnosis code second, says Young, consultant with Young Medical Consulting in East Lansing, Mich. It doesn't make billing sense to have a diagnostic procedure that is not linked to a specific diagnosis, she explains. So link that procedure to diagnosis number two, which is the diagnosis for the polyp.

How it works: In the scenario above with the polypremoval by snare technique, for example, you would list the V code (V76.51) first and polyp diagnosis (such as 211.3, Benign neoplasm of other parts of digestive  system; colon) second.