If the physician has not stated it as screening, do not use V76.51. If yes then 45385-V76.51-211.3
Link Polyp Code As Secondary Diagnosis For Abnormal Findings
Suppose the gastroenterologist discovers a lesion during the exam. Because this colonoscopy is no longer a screening exam, you should strike the G code from your coding possibilities.
Instead, rely on a diagnostic colonoscopy code that appropriately identifies the physician’s ensuing treatment (i.e., biopsy or removal). Remember, you should use Medicare-specific G codes for screenings only. The Medicare Benefit Policy Manual (280.2.2.C) states, “If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than G0105.”
If the physician biopsies a polyp during the exam, you would report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).
If he removes the polyp by snare technique during the exam, you would code 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). If the physician used hot biopsy forceps to remove the polyp, you would report 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery).
Caveat: You should retain the appropriate V code as your primary diagnosis even if the physician biopsies or removes a lesion during what began as a screening colonoscopy. According to the MLN Matters article Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscsopy, “CMS advises that, whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination.” (You can find this article at http://www.cms.gov/MLNMattersArticles/downloads/se0746.pdf.)
However, you should link an appropriate polyp diagnosis to the therapeutic colonoscopy (CPT® Category I) code. So, if our first example of a 65-year-old Medicare patient turns into a colonoscopy with biopsy from the original screening colonoscopy, you would report 45380, and list V10.05 as primary diagnosis, and an ICD-9 code describing the polyp as secondary diagnosis (e.g., 211.3, Benign neoplasm of colon).