Wiki Outpatient Colonoscopies

[Becca2023]

Two questions:

1.) If a patient has a positive cologuard but no history of polyps, should I use the Z12.11 first then the R19.5? Or drop the Z12.11 and use the R19.5 first?

2.) If a patient has a history of polyps and is coming in for a follow-up with no symptoms, do I use the Z12.11 before the Z86.010? Or drop the Z12.11?

Please help. I am getting a lot of rejections.

 

[Patrusheva]

Becca, please refer to https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/
For commercial and Medicaid patients who have a colonoscopy following a positive non-invasive CRC screening test, use modifier 33 with the appropriate colonoscopy code (e.g., 45378, 45380) based on the procedure(s) performed.
For Medicare beneficiaries who have a colonoscopy following a positive result for any of the following non-invasive stool-based CRC screening tests on or after 1/1/2023, use the appropriate HCPCS codes G0105 or G0121 with the KX modifier.

Screening guaiac-based fecal occult blood test (gFOBT) (CPT 82270)

• Screening immunoassay-based fecal occult blood test (iFOBT) (HCPCS G0328)
• Cologuard™ – multi-target stool DNA (sDNA) test (CPT 81528)

If modifier KX is not added to G0105 or G0121 for colonoscopy following a positive non-invasive stool-based test, Medicare will return the screening colonoscopy claim as “unprocessable.” If this happens, add modifier KX and resubmit the claim.

If polyps are removed during a screening colonoscopy for a Medicare patient, use the appropriate CPT code (45380, 45384, 45385, 45388) and add modifier PT (colorectal cancer screening test; converted to diagnostic test or other procedure) to each CPT code. However, it is important to note that if a polyp is removed during a screening colonoscopy, the Medicare beneficiary is responsible for 15% of the cost from 2023 to 2026. This falls to 10% of the cost from 2027 to 2029, and by 2030 it will be covered 100% by Medicare. Some Medicare beneficiaries are not aware that Medicare has not fully eliminated the coinsurance responsibility yet.

 

[TThivierge]

Becca
If the colonoscopy report show doctor/provider collect polyps add each place where bx was taken see ICD10 dx D12 D3A, D01, D04, C49 or C7A, K92.89,dx. blocks. Use the D12 as first dx or K63.5 Polyps but not both. If the patient is discovered to have colon cancer add this dx code first. The payers like details to compare to lab test given on bx. Also use most Z dx LAST on claim. If the patient has problem such as K46, or K92.89 or K59 or R19.7or R15 and provider wants to do colonoscopy as digestive screening add this first on dx claim but of course need documentation to support it. The G codes are used for Medicare patients.If pt had history of polyps use Z86 as last dx. Also Z12.11 is not acceptable s first dx. I d use K92.89 first then last dx Z12.11 if pt has digestive problems if supported and doc wants a screening. If patient has other digestive problems ..code this first, I d use that first then dx Z12.11
I hope helped you and this is the rule about dx Z12.11 in the ICD10 manual..It is not principle first dx. Some Z dx codes are first listed but many are not
Lady T

 

[TThivierge]

Two questions:

1.) If a patient has a positive cologuard but no history of polyps, should I use the Z12.11 first then the R19.5? Or drop the Z12.11 and use the R19.5 first?

2.) If a patient has a history of polyps and is coming in for a follow-up with no symptoms, do I use the Z12.11 before the Z86.010? Or drop the Z12.11?

Please help. I am getting a lot of rejections.

Becca
I hope helped you understand coding disgestive colon bx better. See my other response
Lady T