Outpatient Facility Coding Alert

Published on Wed Feb 19, 2014 PDF

Question: Should we use G0105 or 45380 when we bill a screening colonoscopy for a high risk Medicare patient?

Florida Subscriber

Answer: When reporting a screening colonoscopy for a high risk Medicare patient, you should submit the claim with the appropriate G code — namely, G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). You should also report the appropriate diagnosis code to support your claim for G0105. For instance, if the patient previously had surgery for a colon cancer you would report the V code, V10.05 (Personal history of malignant neoplasm of large intestine) as the primary diagnosis.

If the patient was not a Medicare patient and you were reporting the screening colonoscopy to a commercial carrier, you would use the CPT® code 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]) for the procedure. In this case, you have to use the modifier 33 (Preventive services) to let the payer know that the service was a screening. Again, you have to report the appropriate diagnosis code such as V10.05 to support the service that was provided.

During the screening colonoscopy, if your clinician found polyps that he biopsied, then you do not report the procedure with G0105 or 45378. In such a case, where the screening turns diagnostic, you will have to use the appropriate therapeutic CPT® code instead of the G code. Since your clinician biopsied the lesions, you will then report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) to report the procedure performed.

Don’t forget: Remember to attach 211.3 (Benign neoplasm of other parts of digestive system; colon) to 45380 to represent the patient’s polyps, if benign, and to support the claim for 45380. Append the modifier 33 to let the payer know that the service was initiated as a screening.