5 Common GI/Endoscopy Coding and Billing Mistakes
1. Control of bleeding not separately billable. The control of bleeding is included in biopsy (and most other) endoscopic procedures, and is not separately billable unless the patient comes into the facility with a GI bleed, which is the reason the procedure is being performed – which rarely occurs in the ASC setting.
Control of bleeding can be obtained through means of injections, as well as cauterizations. Injections of epinephrine through an upper endoscopy are coded as 43255. This injection would be included in the ASC facility fee and would not be reimbursed separately from an esophagogastroduodenoscopy or colonoscopy procedure unless the endoscopy case is completed and the patient is in the PACU/recovery area when the bleed occurs, necessitating a return to the OR to treat the hemorrhage.
The control of bleeding by colonoscopy is coded 45382. Append the -78 modifier to the CPT code for the return to the OR for control of bleeding procedures.
2. Only bill for successful surgery. If the physician performing a colonoscopy attempts — but fails — to remove a polyp by snare technique, but he/she is successful at removing the polyp via another technique (such as hot biopsy forceps), only bill the CPT code for the technique/procedure which was successful (use code 45374 for a hot biopsy forceps polypectomy in this case).
For either a colonoscopy or EGD procedure, if a lesion is biopsied and then subsequently the same lesion is removed during the same operative session, code the removal of the lesion only — the biopsy would be considered incidental and not separately billable.
For either a colonoscopy or EGD procedure, if one lesion is biopsied and a separate lesion is removed during the same operative session, code both the biopsy of the lesion and the removal of the separate lesion. Append a -59 modifier to the biopsy procedure if it is unbundled in the CCI unbundling edits.
3. Don't get tripped up by "cold" v. "hot" snare. For colonoscopy procedures performed involving biopsies and/or the removal of a polyp using the cold biopsy forceps method, bill the 45380 CPT code once for any of the following situations:
- The physician takes a single biopsy or multiple biopsies of lesions.
- For the removal of portions of a polyp by cold biopsy forceps.
- For the removal of an entire polyp by cold biopsy forceps technique.
The cold biopsy forceps method is referred to as "cold" since electric current is running to the instrument and no cauterization of bleeding takes place during the removal of tissue.
If the physician performs a snare polypectomy and refers to the technique as "cold snare" or "hot snare," the mention of temperature does not change the coding — the 45385 snare polypectomy code would still be used in either case.
4. Use proper modifiers for incomplete colonoscopies. For both EGD and colonoscopy procedures, a "separate site," for definition purposes, can be a separation between lesions as small as one centimeter. To qualify for billing a colonoscopy code, the scope must move beyond the splenic flexure of the colon. If the scope is not able to move that far, and is only used to examine as far as the sigmoid colon and a portion of the descending colon, it should be coded as 45378 with a -52 or -74 Modifier — depending upon the payor's modifier requirements.
In a colonoscopy, if the patient has a particularly long GI tract and the physician runs out of scope before viewing the entire colon (for example, the scope goes past the splenic flexure but does not extend all the way to the cecum), these procedures should be coded with a -52 Modifier appended for billing purposes.
Failed colonoscopies may also be referred to as "incomplete." Sometimes the physician states the procedure is not completed due to a "poor prep." This occurs when the scope is not able to be advanced past the splenic flexure. Causes of this problem include incomplete preps, unusual patient anatomy, the patient has an obstructing lesion or the provider performing the procedure is inexperienced. These procedures are coded as 45378, with the -52 or -74 modifier indicating a discontinued procedure – the choice of modifier depends on the payor's requirements.
5. Follow proper, current rules for screening procedures. The latest Medicare guidance for the situation where a colonoscopy is scheduled as a screening procedure but a polyp is removed and/or a biopsy is taken, is to not bill the G-code for a screening study but bill the appropriate CPT codes for the procedure(s) performed (45385, 45380-59, etc.). On the claim form, list the diagnoses in field 21 with the screening V-code (V76.51) first followed by the 211.3 polyp or other applicable diagnosis code(s). When linking the diagnosis to the procedure in field 24E of the CMS-1500 claim form, only link the 211.3 polyp code with the 45385 or other colonoscopy code and do not link the screening V-code in field 24E to any procedure code billed. If your Medicare carrier specifically directs billing these procedures in another manner, follow its guidance.
Note: CPT codes are copyrighted by the AMA.
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