Part B Insider (Multispecialty) Coding Alert

Published on Tue Jan 27, 2004 PDF

Certain conditions can call for either type of colonoscopy

A patient comes in with a pre-existing diagnosis, and your physician performs a colonoscopy. Should you bill it as a diagnostic or as a screening colonoscopy? There's no clear answer.
 
"It's a very tough subject that's been plaguing a lot of people," says Carol Pohlig, a coder with the department of medicine at the Hospital of the University of Pennsylvania.
 
And many providers have been billing incorrectly recently, according to Part B carrier Cahaba GBA. In an October 2003 notice, Cahaba warns that "providers are incorrectly billing for a diagnostic colonoscopy when they should be billing a screening colonoscopy."
 
The problem is that certain conditions could call for either a diagnostic (CPT 45378 ) or a screening (G0105) colonoscopy. In particular, Crohn's disease, ulcerative colitis, or other inflammatory bowel disease could justify a diagnostic colonoscopy, but only under certain circumstances. "In those cases it's very hard for the physician to evaluate whether it's appropriate to bill a screening colonoscopy or a diagnostic colonoscopy," Pohlig says.
 
What makes it tricky is you're checking on a chronic condition, says coder Stacy Maloney with Commonwealth Gastoenterology Associates in Lexington, Ky.
 
Often, carriers will impose time-based criteria for diagnostic colonoscopies for patients with those diseases. For example, WPS Medicare Administrators and many other carriers will only cover diagnostic colonoscopies for patients with Crohn's or ulcerative colitis if they've had the condition on their entire colon for eight years or more, or on the left side of the colon for 15 years or more.
 
"Those criteria are so specific it's very difficult for the physician to be able to identify how long" a patient has had a condition, Pohlig says, "unless you have a strong scheduling team when they schedule the colonoscopies, and the billing as well."
 
WPS will also cover diagnostic colonoscopies for unexplained rectal bleeding, diarrhea accompanied by weight loss, or chronic inflammatory bowel disease of the colon if a more precise diagnosis or a determination of the extent of the disease will influence the physician's management, among other conditions. (See www.wpsic.com/medicare/policies/wisconsin/gi06.shtml for the full list.)