General Surgery Coding Alert

Question: A screening colonoscopy for a patient resulted in a biopsy. The patient has Medicare, and when I billed 45384, Medicare paid at 80 percent of the allowable. The patient told me that Medicare is supposed to cover screening colonoscopies at 100 percent per his handbook. Is this correct, and if so, how should I code this?

Rhode Island Subscriber

Answer: The patient is correct that Medicare covers screening colonoscopies at 100 percent (assuming appropriate age, frequency, and ordering diagnosis), but that diagnostic colonoscopies are subject to deductible and coinsurance.

Medicare provides two "G" codes for screening colonoscopies: 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 would expect the physician to order a screening test in the absence of signs or symptoms of disease using a diagnosis code such as V76.51, (Special screening for malignant neoplasms; colon), and an additional code such as V16.0 (Family history of malignant neoplasm; gastrointestinal tract) to support G0105.

If the surgeon identifies and removes a polyp or lesion during the procedure, you should not use a "G" code, but instead you should report the appropriate surgical code such as 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s), polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery).

Use modifier: Providers should append modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure) "to the diagnostic procedure code that is reported instead of the screening [test] when the screening test becomes a diagnostic service," according to the Medicare Physician Fee Schedule Final Rule published in the Nov. 29, 2010 Federal Register. In the above example, that means reporting 45384-PT.

Medicare will respond to the modifier by waiving the deductible for all surgical services on the same date as the diagnostic test -- that means the deductible will be waived, but coinsurance may still apply.

Don't drop the "V" code: "Whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening ... colonoscopy ..., the primary diagnosis should be indicated ... using the ICD-9 code for the screening examination," states Medicare Learning Network (MLN) Matters article SE0746. You should report the findings from the biopsy as the secondary diagnosis, such as 211.3 (Benign neoplasm of other parts of digestive system; colon).

You can read more about this at https://www.cms.gov/transmittals/downloads/R864OTN.pdf.