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Coder's Guide to Surgery Center Colonoscopies

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CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

 

The following article is written by Rosalind Richmond, chief coding and compliance officer for GENASCIS.

 

There are two types of colonoscopy services: diagnostic or therapeutic. In some cases a diagnostic colonoscopy may be converted from diagnostic to therapeutic based on the patient's clinical findings and the procedure performed.

 

Screening colonoscopy

Screening Colonoscopies are performed on patients that have no presenting signs or symptoms related to the digestive system, but have reached the age for routine screenings.

 

ICD-9- CM diagnosis code V76.51 (Special screening for malignant neoplasm, colon) is always the first listed diagnosis code regardless of the findings. All additional findings are reported as secondary codes.

 

The following ICD-9-CM diagnostic V-codes should be listed as secondary codes when the information is listed in the patient's record (usually in the history and physical). The following codes also note that the patient is considered high risk (See high risk circumstances below.)

V10.05

Personal history of malignant neoplasm, large intestine

V12.72

Personal history of colonic polyps

V16.0

Family history of malignant neoplasm, gastrointestinal tract

 

High risk is coded when any of the following conditions are noted by the provider or in the patient's history:

  • Close relative (sibling, parent, or child) has had colorectal cancer or an adenomatous polyposis
  • Family history of hereditary nonpolyposis colorectal cancer
  • Personal history of adenomatous polyps
  • Personal history of colorectal cancer
  • Personal history of inflammatory bowel disease, Crohn's disease, or ulcerative colitis

 

For screening a colonoscopy when no procedure beyond the diagnostic endoscopy is performed, CPT/HCPCS code assignment depends on the patient's payer. If the payor is Medicare, one of two HCPCS codes is required:

G0105

Colorectal cancer screening; colonoscopy on individual at high risk

G0121

Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

 

If the payor is Non-Medicare and no procedure is performed beyond the diagnostic endoscopy the following CPT code is assigned:

45378

Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression


Therapeutic colonoscopy

When signs and symptoms are related to the GI tract (i.e., abdominal pain, blood in stool, chronic diarrhea, change in bowel habits, weight loss or blood loss anemia), the above mentioned V-code (V76.51) should never be assigned. A symptom code should be assigned when there is no definitive diagnosis. If the patient's history notes a family history or personal history of colonic malignancy or polyps, the appropriate V-code from the box above should be assigned as a secondary code.

 

CPT codes 45380-45385 are used to report procedures through the colonoscope. Therapeutic colonoscopies include a diagnostic component; code 45378 is not reported with the services below.

 

These codes include:

45380

With biopsy, single, or multiple
(For procedures stated to be by cold biopsy forceps)

45381

With directed submucosal injection(s) any substance

45382

With control of bleeding ( e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)

45383

With ablation of tumor(s), polyp(s),, or other lesion(s) not amendable to removal by hot forceps, bipolar cautery or snare technique

45384

With removal of tumor(s), polyp(s) , or other lesion(s) by hot biopsy forceps or bipolar cautery

45385

With removal of tumor(s), polyp(s), or other lesion(s) by snare technique

 

For CPT codes 45383-45385, only one code should be assigned even if multiple lesions or polyps are treated with the same technique.

 

Example: The gastroenterologist used hot biopsy forceps technique to perform polyp removals at different sites at the same time — report CPT code 45384 only once.


Note: The words in the CPT description for codes 45383-45385 — "tumor(s), polyp(s), or other lesion(s)" — indicate that only one code may be assigned per colonoscopy.

 

When the above procedures are performed for a Medicare patient who originated as a screening colonoscopy, the HCPCS G-code should not be reported. CPT 45378 should not be reported with 45308-45385.


Modifiers -33 and -PT

Assign modifier- 33 to non-Medicare therapeutic procedures and modifier -PT to Medicare therapeutic procedures.


Source: CPT Assistant December 2010 / Volume 20 Issue 12, American Medical Association, CPT 2011 Standard Edition

 

Learn more about GENASCIS.

 

The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.

 

Read more from GENASCIS:

 

- Guidance for Properly Reporting Modifier -33

 

- 2011 CPT Changes to the Integumentary System

 

- Webinar Discusses Keys to Transforming Surgery Centers Into a Profitable Business

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