Modifier Coding Alert

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Gastroenterology: Be Ready With Modifier Knowledge When Screenings Turn Therapeutic

Published on Wed Aug 19, 2015

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Medicare, CPT^® offer different guidance on modifier choices.

When your gastroenterologist performs a screening flexible sigmoidoscopy that turns diagnostic or therapeutic, you’ll need to have sharp modifier skills in order to code the encounter correctly.

Take a look at this inside info on coding screening procedures that turn diagnostic or therapeutic —– and which modifiers you should use when such occasions occur.

Physicians Use Flex Sig To Simplify Screenings

Providers often perform a flexible sigmoidoscopy to screen for colorectal cancer if the patient has signs or symptoms of gastrointestinal disease. In the procedure, the physician uses a flexible endoscope to reach up to 60 centimeters from the anus and view the distal portion of the colon up to the splenic flexure.

Therefore, this procedure will not be able to give information about any malignancies or polyps in the proximal part of the colon, which a colonoscopy can. However, unlike a colonoscopy, this procedure is simpler to perform due to non-necessity of sedation and less rigorous prep.

Observe Limits For Covered Screenings

Section 4180 of the Medicare Carriers Manual stipulates that Medicare accepts screening flexible sigmoidoscopies once every four years for low risk patients as one of the options for colorectal cancer screening. At least 47 months must have passed since the month in which a prior sigmoidoscopy was performed for screening. In case the patient has already undergone a screening colonoscopy but not a sigmoidoscopy, Medicare will cover the next screening sigmoidoscopy only after a minimum of 10 years (119 completed months) after the colonoscopy. However, this limitation is waived off for patients at high risk for colorectal cancer.

You should use HCPCS code G0104 (Colorectal cancer screening; flexible sigmoidoscopy) to report Medicare screening flexible sigmoidoscopy performed on patients without signs or symptoms of gastrointestinal disease. Report with code 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) for a diagnostic flexible sigmoidoscopy performed on patients with signs and symptoms of gastrointestinal disease.

Remember Modifiers When Screening Turns Therapeutic

If a patient presents for a screening sigmoidoscopy without any symptoms, and the screening turns diagnostic or therapeutic, you’re going to need to choose the proper modifier — and the modifier will depend on the payer, warns Jan Rasmussen CPC, PCS, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions, Holcombe, Wisc.

Example: An asymptomatic patient presents for a screening sigmoidoscopy. The physician performs the procedure and detects polyps in the distal colon. He proceeds to remove the polyp(s) with one or more methods. This case is a typical example where a screening visit turns into a therapeutic session. If a lesion or growth is detected that results in a biopsy of the growth, you can report 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple). If you are reporting a removal, your code choice will depend on the technique used. You can use 45333 (Sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps) or 45338 (Sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Remember: Append modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure) to the procedure code for Medicare payers, and payers that follow Medicare payment guidelines. CMS uses this HCPCS modifier to indicate that the physician began a colorectal screening service (in this case a flexible sigmoidoscopy), but then switched to a therapeutic option for the benefit of the patient.

For commercial insurers that don’t follow Medicare coding protocol, there is a corresponding CPT^® modifier to use when a screening services turns diagnostic or therapeutic. In these cases, you’ll append modifier 33 (Preventive services) to the procedure code, informs Michael Weinstein, MD, vice president and member of the Board of Managers for Capital Digestive Care, a multi-office practice in the Washington, D.C. area. Use this modifier on screening services that turn diagnostic or therapeutic for private payers that require it.