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Billing for an E/M prior to a colonoscopy

Dana Posted Mon 28th of October, 2019 12:16:27 PM
For Medicare Patients who call our office and request a screening colonoscopy because of family history or personal history of polyps, does Medicare allow an office visit prior to the colonoscopy because they are considered high risk? On the contrary, if they are coming in for a screening colonoscopy and we are using z12.11 screening dx code, does this prevent us from billing an office visit? If we uncover in the office visit that they have a symptom, such as diarrhea, would this prevent the colonoscopy from being a screening procedure?
SuperCoder Answered Tue 29th of October, 2019 04:06:20 AM

Hi Dana,

Thank you for your question.

Before we go ahead and come up with conclusion for the above scenario, it is important to understand screening colonoscopy and diagnostic colonoscopy.

A screening colonoscopy is performed on patients who do not have signs or symptoms and there are no significant findings found during the examination.

A diagnostic colonoscopy is defined as one performed to evaluate signs or symptoms of disease.

As per CMS guidelines Medicare does not cover an E/M prior to a screening colonoscopy.

As per above scenario, report a screening colonoscopy for a Medicare patient using G0105 (colorectal cancer screening; colonoscopy on individual at high risk) and common ICD-10 for colorectal cancer screening include:

Z86.010 (personal history of colonic polyps).

Z12.11 (encounter for screening for malignant neoplasm of colon)

Z80.0 (family history of malignant neoplasm of digestive organs)

 

NOTE:

Medicare considers an individual at high risk for developing colorectal cancer as one who has one or more of the following:

A family history of familial adenomatous polyposis or nonpolyposis colorectal cancer, personal history of adenomatous polyps or colorectal cancer, Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis. 

 

Also, if we uncover in the office visit that they have a symptom, such as diarrhea, this would not prevent the colonoscopy from being a screening procedure, however, it is only If a lesion or growth that results in a biopsy or lesion/growth removal is detected during a screening colonoscopy, the appropriate CPT code for diagnostic colonoscopy with biopsy or lesion/growth removal (instead of screening) should be billed with modifier PT (colorectal cancer screening test, converted to diagnostic test or other procedure).

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