Wiki Mod 33 - Colonscopy

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KoBee

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Our billing dept has reached out to recheck coding using mod 33 due to denials, anyone else getting denied for mod 33. Could we be adding it incorrectly?

A 52 yr
CPT 45378
Mod 33

Dx
Z12.11 screening
Z57.30 Diverticulosis
K64.9 hemorrhoids

or

A 63 yr
CPT 45378
Mod 33

Dx:
Z12.11 screening
Z86.020 personal hx of polyps
K64.8 hemorrhoids
 
if this is a Medicare patient, they want modifier -PT and not the -33.

otherwise, this looks correct to me.
I do not code colonoscopies, but I have been researching the 2023 updates, so I've been going over a lot of this info, this morning.
 
lgardner said:
if this is a Medicare patient, they want modifier -PT and not the -33.

otherwise, this looks correct to me.
I do not code colonoscopies, but I have been researching the 2023 updates, so I've been going over a lot of this info, this morning.
Click to expand...
These are commercial plans, thank you for your help, i can't really pinpoint what the issue is. Only thing i can think of is maybe they dont want the mod 33 if Z code, but then again without 33, payer will bill patient for copayment, right?
 
KoBee said:
These are commercial plans, thank you for your help, i can't really pinpoint what the issue is. Only thing i can think of is maybe they dont want the mod 33 if Z code, but then again without 33, payer will bill patient for copayment, right?
Click to expand...
yes. that is my understanding.

I wish I could offer some more guidance.
 
Kobee
Why are you using dx Z12.11 as first dx code? I'd use the definitive problem they arrived for FIRST such as K64 or K57.30 per documentation then Z code last. Your sequencing matters in order to get proper payment.
Well hope helped you a little bit
Lady T
 
TThivierge said:
Kobee
Why are you using dx Z12.11 as first dx code? I'd use the definitive problem they arrived for FIRST such as K64 or K57.30 per documentation then Z code last. Your sequencing matters in order to get proper payment.
Well hope helped you a little bit
Lady T
Click to expand...
I'm sorry, but this is not correct.
If a screening procedure, turns into a diagnostic procedure, the screening code is listed first, followed by any findings.

Per CodingIntel:
Q: If a test is scheduled as a screening (colonoscopy) and a polyp is found, how should these be sequenced?

For example:

  • Z12.11 encounter for screening for malignant neoplasm of colon
  • K63.5 polyp of colon
A: The screening code (Z12.11) would go first followed by any findings.

Citation: ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page 8 Effective with discharges: March 13, 2017 states that whenever a screening examination is performed, the screening code is the first-listed coded. The fact that the test is a screening remains, regardless of the findings or any additional procedure that is performed as a result of the findings.

Remember that once the polyp is removed the patient follow up visits should not be code with K63.5, polyp of colon. Then, use code Z86.010, personal history of colonic polyps

per ICD-10 guidelines:
Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis. The Z code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.
 
Hi Everyone,
The patient scenarios above from Kobee had definitive gastro problems thus reason physician wanted to do a colonoscopy. Id bill that first and then the Z12.11. It is not wrong. Medical necessity with patient's illness COULD be the rationale of using CPT 45378. and dx diagnostic reason as first then Z12.11. Also here is info from the AAPC knowledge below .
Scenario 2:
Indication: Iron deficiency anemia, screening colon

Procedure performed: Colonoscopy

Coding: CPT 45378, Dx D50.9, Z12.11

Rationale: Screening is always performed on asymptomatic patients. As the reason for the visit is iron deficiency anemia, the test would be considered diagnostic even though a screening colonoscopy is specified. This scenario is considered a diagnostic colonoscopy so it is coded without modifiers 33/PT and the diagnosis is sequenced before the encounter code.

Reference Code Colonoscopies With Precision - AAPC Knowledge Center https://www.aapc.com/blog/84107-code-colonoscopies-with-precision/Mar 1,2022 AAP Knowledge Center.​

Patient's documentation by the provider's can vary in which code accordingly.
Have a good day

Lady T
 
I don't see anything in the poster's original question that states it was intended to be diagnostic vs screening.

there are some definite inconsistencies worth questioning.
the cpt code 45378 is for a diagnostic colonoscopy.
However, the dx is for screening (although, other dx are also reported) and they are using a modifer 33, which is for preventive services.

so, Kobee - was the original intention of the colonoscopy for screening or diagnostic purposes?
the answer may help solve the issue.
 
lgardner said:
I don't see anything in the poster's original question that states it was intended to be diagnostic vs screening.

there are some definite inconsistencies worth questioning.
the cpt code 45378 is for a diagnostic colonoscopy.
However, the dx is for screening (although, other dx are also reported) and they are using a modifer 33, which is for preventive services.

so, Kobee - was the original intention of the colonoscopy for screening or diagnostic purposes?
the answer may help solve the issue.
Click to expand...
hi there - sorry, for the confusion, intention for these were screenings, K Dx are from findings after which become diagnostic.
 
I am not a gi coder, but these look correct to me.
I think that I would try using only the Z12.11 (and maybe the Z86.010).
 
TThivierge said:
Hi Everyone,
The patient scenarios above from Kobee had definitive gastro problems thus reason physician wanted to do a colonoscopy. Id bill that first and then the Z12.11. It is not wrong. Medical necessity with patient's illness COULD be the rationale of using CPT 45378. and dx diagnostic reason as first then Z12.11. Also here is info from the AAPC knowledge below .
Scenario 2:
Indication: Iron deficiency anemia, screening colon

Procedure performed: Colonoscopy

Coding: CPT 45378, Dx D50.9, Z12.11

Rationale: Screening is always performed on asymptomatic patients. As the reason for the visit is iron deficiency anemia, the test would be considered diagnostic even though a screening colonoscopy is specified. This scenario is considered a diagnostic colonoscopy so it is coded without modifiers 33/PT and the diagnosis is sequenced before the encounter code.

Reference Code Colonoscopies With Precision - AAPC Knowledge Center https://www.aapc.com/blog/84107-code-colonoscopies-with-precision/Mar 1,2022 AAP Knowledge Center.​

Patient's documentation by the provider's can vary in which code accordingly.
Have a good day

Lady T
Click to expand...
This scenario would not be considered a screening due to the patient have IDA. The original post is questioning the use of modifier 33 when billing an actual screening with or without findings. When screening colonoscopies result in a procedure, the first diagnosis is always Z12.11 to indicate the original purpose of the colonoscopy.
 
If no biopsies were done and code 45378 is the correct code, no modifier is needed as the DX of Z12.11 designates the procedure as a screening. The only time a modifier 33-commerical or PT-Medicare is needed is if a biopsy is done.
 
I do gastro coding all day every day. I am not sure what area you are in or what commercial payers you are dealing with, but in Oklahoma the majority of the commercial payers we deal with, recognize G0121 for screening colonoscopy or G0105 for high risk screening colonoscopy. They also recognize the PT modifier if the screening turns diagnostic (ex. 48380-PT, 45384-PT, 45385-PT etc.,).
I did see a response above suggesting you needed to put your definitive diagnosis as the primary diagnosis, but that is not correct for screening or high risk screening colonoscopy. You need that Z12.11 along with the proper CPT/CPT modifier to trigger the screening benefits and to meet medical necessity. If a diagnosis other than Z12.11 is used with G0121 you will have LCD/Medical necessity issues.
In order for the procedure to be a screening, the patient must by asymptomatic.
Hope this helps!
Kim Boyd, CPC
 
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