Wiki Colonoscopy after a positive stool test.

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vickymazza

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According to The No Surprise Act any colonoscopy done after a positive result from a stool-based screening test will be prevented under new federal rules. Insurance plans are required to implement the new USPFTF screening benefit for those 45 and older for plan or policy years beginning May 31, 2022. The way this reads my question is, does this mean any policies starting on January 1, 2022 this new rule would not apply to? And does anyone have guidance on how to code these colons after the positive stool test?
Thanks for any help!!
 
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Yes, my understanding is that the new requirement is not in effect for policies beginning prior to May 31, 2022. Plans covered by the law have been given until this date to bring their policies into compliance, though some may have already started earlier.

As far as I know, there haven't been any new general coding guidelines issued for this. Codes are always assigned based on provider documentation, and the new guidance applies coverage and reimbursement by payers, not coding or reporting by providers, so I wouldn't expect new ICD-10 guidelines to be issued specifically for this. However, individual payers might update their coding and reimbursement policies to make it clear how they would require this particular situation to be reported in order to ensure correct payment - I'd recommend keeping an eye on your bigger payers' policy updates for additional information.
 
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thomas7331 said:
Yes, my understanding is that the new requirement is not in effect for policies beginning prior to May 31, 2022. Plans covered by the law have been given until this date to bring their policies into compliance, though some may have already started earlier.

As far as I know, there haven't been any new general coding guidelines issued for this. Codes are always assigned based on provider documentation, and the new guidance applies coverage and reimbursement by payers, not coding or reporting by providers, so I wouldn't expect new ICD-10 guidelines to be issued specifically for this. However, individual payers might update their coding and reimbursement policies to make it clear how they would require this particular situation to be reported in order to ensure correct payment - I'd recommend keeping an eye on your bigger payers' policy updates for additional information.
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Thank you.
 
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Can someone tell me how this would be coded? Z12.11 followed by R19.5 and any findings? Also, just so I am understanding that any policies prior to May 31,2022 will not cover this? Thanks for the help
 
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lamiller said:
Can someone tell me how this would be coded? Z12.11 followed by R19.5 and any findings? Also, just so I am understanding that any policies prior to May 31,2022 will not cover this? Thanks for the help
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I have many questions about the new guidelines. If we follow what many commercial guidelines tell us, Z12.11 is used in the absence of symptoms or findings. R19.5 is a finding so I do not think Z12.11 would be applicable. However, under the guidelines, a follow up colonoscopy for a positive non-invasive screening result should be paid without cost sharing. I feel there needs to be a new code or at least a new modifier we can use to tell the insurance the colonoscopy is follow up after a positive result of a non-invasive screening test. I have checked Aetna commercial guidelines (clinical policy bulletin) and there is no addition or verbiage regarding the new ACA guidelines that I can find.
 
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bethb said:
I have many questions about the new guidelines. If we follow what many commercial guidelines tell us, Z12.11 is used in the absence of symptoms or findings. R19.5 is a finding so I do not think Z12.11 would be applicable. However, under the guidelines, a follow up colonoscopy for a positive non-invasive screening result should be paid without cost sharing. I feel there needs to be a new code or at least a new modifier we can use to tell the insurance the colonoscopy is follow up after a positive result of a non-invasive screening test. I have checked Aetna commercial guidelines (clinical policy bulletin) and there is no addition or verbiage regarding the new ACA guidelines that I can find.
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Has anyone found any updates on this so we know how to bill for it?
 
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I just watched a Noridian webinar on the Medicare Quarterly Updates and this topic came up.

Medicare Physician Fee Schedule Final Rule Summary: CY 2023:

"Expansion of Coverage for Colorectal Cancer Screening and Reducing Barriers
For CY 2023, we’re modifying our policies to expand coverage of colorectal cancer (CRC) screening in 2 ways:
• First, we’re modifying coverage and payment requirements for certain CRC screening tests to start when the individual is 45 years of age or older, including Blood-based Biomarker Tests, The Cologuard™ – Multi-target Stool DNA (sDNA) Test, Immunoassaybased Fecal Occult Blood Test (iFOBT), Guaiac-based Fecal Occult Blood Test (gFOBT), MLN Matters: MM12982 Related CR 12982 Page 4 of 7 Barium Enema Test, and Flexible Sigmoidoscopy Test. Screening Colonoscopy will continue with no minimum age limitation. We aren’t modifying existing maximum age limitations.
• Second, we’re expanding the regulatory definition of CRC screening tests to include a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based CRC screening test returns a positive result. We added the regulatory definition to 42 CFR 410.37.

See MLN Matters Article MM12656 for more information"

the presenter on the webinar stated that, while if a patient has a positive FOBT or Cologuard, they could still have a screening colonoscopy, BUT she didn't have any guidance (at the moment) regarding how to list the diagnoses.
 
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lgardner said:
I just watched a Noridian webinar on the Medicare Quarterly Updates and this topic came up.

Medicare Physician Fee Schedule Final Rule Summary: CY 2023:

"Expansion of Coverage for Colorectal Cancer Screening and Reducing Barriers
For CY 2023, we’re modifying our policies to expand coverage of colorectal cancer (CRC) screening in 2 ways:
• First, we’re modifying coverage and payment requirements for certain CRC screening tests to start when the individual is 45 years of age or older, including Blood-based Biomarker Tests, The Cologuard™ – Multi-target Stool DNA (sDNA) Test, Immunoassaybased Fecal Occult Blood Test (iFOBT), Guaiac-based Fecal Occult Blood Test (gFOBT), MLN Matters: MM12982 Related CR 12982 Page 4 of 7 Barium Enema Test, and Flexible Sigmoidoscopy Test. Screening Colonoscopy will continue with no minimum age limitation. We aren’t modifying existing maximum age limitations.
• Second, we’re expanding the regulatory definition of CRC screening tests to include a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based CRC screening test returns a positive result. We added the regulatory definition to 42 CFR 410.37.

See MLN Matters Article MM12656 for more information"

the presenter on the webinar stated that, while if a patient has a positive FOBT or Cologuard, they could still have a screening colonoscopy, BUT she didn't have any guidance (at the moment) regarding how to list the diagnoses.
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Thank you for this information. So Medicare will also be covering this now? Do you happen to have the link for the article?
 
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lgardner said:
I just watched a Noridian webinar on the Medicare Quarterly Updates and this topic came up.

Medicare Physician Fee Schedule Final Rule Summary: CY 2023:

"Expansion of Coverage for Colorectal Cancer Screening and Reducing Barriers
For CY 2023, we’re modifying our policies to expand coverage of colorectal cancer (CRC) screening in 2 ways:
• First, we’re modifying coverage and payment requirements for certain CRC screening tests to start when the individual is 45 years of age or older, including Blood-based Biomarker Tests, The Cologuard™ – Multi-target Stool DNA (sDNA) Test, Immunoassaybased Fecal Occult Blood Test (iFOBT), Guaiac-based Fecal Occult Blood Test (gFOBT), MLN Matters: MM12982 Related CR 12982 Page 4 of 7 Barium Enema Test, and Flexible Sigmoidoscopy Test. Screening Colonoscopy will continue with no minimum age limitation. We aren’t modifying existing maximum age limitations.
• Second, we’re expanding the regulatory definition of CRC screening tests to include a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based CRC screening test returns a positive result. We added the regulatory definition to 42 CFR 410.37.

See MLN Matters Article MM12656 for more information"

the presenter on the webinar stated that, while if a patient has a positive FOBT or Cologuard, they could still have a screening colonoscopy, BUT she didn't have any guidance (at the moment) regarding how to list the diagnoses.
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Has Medicare released how they expect us to code this in 2023 or are they leaving us hanging?
 
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lgardner said:
per Noridian, Medicare is leaving us hanging (at least for now).
:/
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What are thoughts on coding it like R195, Z12.11 G0121. I guess it's worth a try to see if they will pay? My providers are asking how we will get paid for this of course, all I can tell them is I'm researching it still and there is no guidance on how to bill it. I even attended a Gastro seminar recently and still no answers.
 
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lamiller said:
What are thoughts on coding it like R195, Z12.11 G0121. I guess it's worth a try to see if they will pay? My providers are asking how we will get paid for this of course, all I can tell them is I'm researching it still and there is no guidance on how to bill it. I even attended a Gastro seminar recently and still no answers.
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coding like that was discussed in the webinar and, while no one wanted (or was able) to give a definitive answer, it was speculated that R19.5, Z12.11, might be correct.

I know it's about as clear as mud, but that's what we got (for now).
 
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lgardner said:
coding like that was discussed in the webinar and, while no one wanted (or was able) to give a definitive answer, it was speculated that R19.5, Z12.11, might be correct.

I know it's about as clear as mud, but that's what we got (for now).
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Was there anything mentioned about coverage before May 21, 2022 not being covered for commercial and Medicare patient's?
 
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Hi All. I was reading through the thread and thought I would attach the article from MLN about the expansion of coverage for CRC screenings with a positive stool-based CRC. According to the article, we should append Modifier KX to the screening colonoscopy code to indicate that the service was performed as a follow-on screening after a positive result from a stool-based test. I do not think we would need the R19.5 because of the KX modifier. Sending one out today and will follow-up with result.
 

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  • MM13017.pdf
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MarDee said:
Hi All. I was reading through the thread and thought I would attach the article from MLN about the expansion of coverage for CRC screenings with a positive stool-based CRC. According to the article, we should append Modifier KX to the screening colonoscopy code to indicate that the service was performed as a follow-on screening after a positive result from a stool-based test. I do not think we would need the R19.5 because of the KX modifier. Sending one out today and will follow-up with result.
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I agree....I have gotten this update as well. If the screening colonoscopy followed by positive stool based test becomes diagnostic I believe I would treat it as any regular screening DX codes. No need to put in the R19.5 anywhere, correct?? Now, just to get our providers to put the indication is screening on procedure notes and not positive stool test.
 
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Are we supposed to use the KX modifier for facility as well? we do single path billing and i cannot seem to find if this is also a facility modifier.
 
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MarDee said:
Hi All. I was reading through the thread and thought I would attach the article from MLN about the expansion of coverage for CRC screenings with a positive stool-based CRC. According to the article, we should append Modifier KX to the screening colonoscopy code to indicate that the service was performed as a follow-on screening after a positive result from a stool-based test. I do not think we would need the R19.5 because of the KX modifier. Sending one out today and will follow-up with result.
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Thank you, MarDee, for that MLN PDF! This IS great news!

Questions about this new update for discussion:
1. Do we use KX instead of of PT/33, or in addition to?
2. Are we supposed to use the KX modifier for facility as well? (As DFUGET asked above)
 
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If a patient has scheduled a follow up colonoscopy after a positive stool based test and they have commercial Insurance, is it coded the same as if it was a Medicare patient? Do we code the Commercial payors as a screening but with 33 modifier like the Medicare but with PT/or KX?? Thank you
 
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I know that some insurance companies will cover a colonoscopy consult prior to a screening colonoscopy and there is HCPCS S0285 specifically for this service. However, in your case the patient has a documented complaint for which the colonoscopy has been requested by the PCP so this code wouldn't apply.

Since there is no global surgical period for a colonoscopy, I would say that you need to determine if the E&M meets the criteria as a medically necessary visit and the required elements for billing an E&M are documented in the record. If the provider is performing the E&M on the same day as the colonoscopy then the E&M is generally not payable per the information in Encoder Pro.
 
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I used R19.5 and 45378 with MOD 33 and BCBS commercial won't pay. I will attempt to use G0121 with R19.5 & Z12.11 and see if it works, if anyone has suggestions or accuracy on commercial coding with R19.5 I'm all ears. Thanks
 
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