Guidelines for When to Code for Screening and Diagnostic Colonoscopies in an ASC

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Differences in coding for screening or diagnostic colonoscopies have been a pressing issue for more than a decade and the new health reform law will make it all the more important. The law requires private insurers to provide first-dollar coverage for colorectal screenings within six months after enactment and stops requiring co-pays for Medicare beneficiaries for such screenings on Dec. 31, according to the Colorectal Cancer Coalition. But the coalition adds that regulations still have to be written interpreting the law.

First, it is important to understand what a screening colonoscopy is. It is a procedure on a patient who has no symptoms. It involves looking but not touching, because nothing has been found in the screening. Commercial payors accept either of two coding possibilities for screening colonscopies. Some payors accept the HCPCS code G0121 (screening colonoscopy for average risk), initially only used by Medicare but now more widespread among commercial payors. Other payors, however, accept CPT 45378 (colonoscopy diagnostic) with a diagnosis code of V76.51 (colon screening for malignant neoplasm).

However, if a polyp or lesion is found and removed by snare during the screening colonoscopy, coding becomes more complicated. Now the procedure is billed as 45385 (colonoscopy with lesion removed by snare) and the selection of diagnosis code is a little more tricky.

CMS requires the facility to bill for both the indication (screening) and the finding (polyp). On the HCFA 1500 form, you would enter V76.51 as the first diagnosis and 211.3 as the second diagnosis but link the procedure to 211.3. Most billing software systems for facility payment would allow you to bill accordingly, but some software does not allow you to pick or rank the diagnosis code. With these systems, you would have to bill 211.3 as primary and V76.51 as secondary.

Commercial payors should allow you to bill that way, but they may not make a distinction between preventive coverage and diagnostic coverage. If they do make a distinction, they usually pay more for preventive than for surgical care. That is, the patient usually pays more out-of-pocket when a surgical endoscopy is done. And instead of a HCFA 1500 form, the commercial payor requires a UB-04 billing form, which is not as flexible and doesn't handle comments or the ranking of codes as easily as the HCFA-1500 form.

Here are some guidelines for the screening colonoscopy.

Verify patient benefits and secure preauthorization. This usually requires two different phone calls to the payor. Ask what benefits the patient has with a diagnosis code of V76.51 for screening versus a diagnosis code of 211.3. Usually the provider, not the facility, makes the call, but make sure someone is calling. Misunderstandings can arise particularly when the ASC and physician's office are not linked.

Review possible payments with patient beforehand. Have a conversation with patients prior to the procedure, reviewing coverage and, in particular, making sure they know what "screening" means. Don't assume the physician's office did this, because patients often come to the ASC not even knowing why the procedure is being performed. They may be in for a very unpleasant surprise. It is not unusual for the patient to pay only a $50 deductible when V76.51 (screening) is assigned to the claim, but a $3,000 deductible when 211.3 (removal) is assigned. The patient should be informed that a surgical colonoscopy is a good possibility, because at least 35 percent of screening colonoscopies end up as surgical colonoscopies, according to the American Gastroenterological Association.

Always use both diagnosis codes.
Some payors still pay according to the intent of the procedure. That is, they will pay for a screening if that was what the patient came in for, even if a polyp is found. For this reason, it is vital to assign both diagnosis codes to the claim.

How to deal with screening when a lesion is found.
If a lesion is found during the colonoscopy, both the indication of screening and the finding should be billed.

Bills can be rejected when codes are in the wrong order.
Sometimes the patient tells you the insurance company said the procedure was billed incorrectly because the diagnosis codes were in the wrong order. In these cases, review the claim and resubmit it in the order the insurer uses. This happens because the payor's software will only register one diagnosis code even if two are provided. This can also happen when multiple endoscopies are billed and different lesions or findings are handled with different surgical techniques. Even though the coder enters the claims and links each diagnosis to the procedures, the payor's software doesn't have the ability to see this.

Do not cite a symptom for a screening.
If the procedure is a screening colonoscopy, the indication should not be a symptom. The gastroenterologist should be alerted and the note amended.

Kathleen Mueller can be reached at

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

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