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CINDY Posted Fri 27th of July, 2018 17:25:53 PM
We are having difficulty understanding the numerous guidelines set forth in regard to billing for screening colonoscopies. Unfortunately even our insurance provider representatives do not understand their own guidelines, and are unable to give us any answers. I would like to know how the below scenarios should be billed: (1) Non-Medicare patient presents with family history of polyps. We typically bill this with a G0105 (high risk) if there were no polyps or biopsy. Other wise we bill 45385 with modifier to indicate started as a screening, with the primary diagnosis of Z83.71 followed by the 2nd diagnosis of the polyp finding. A lot of our insurance companies are stating that family history of polyps is not considered a screening even when their guidelines state it is. BCBS Al. stated that we should be billing all of our screening colonoscopies using the ICD 10, Z12.11 (screening for malignant neoplasm), followed by the family history of colon polyps code, and lastly the finding of any polyp/biopsy. Could you please assist in suggesting the correct way of coding for screening colonoscopies?
SuperCoder Answered Mon 30th of July, 2018 10:32:44 AM

Hi Cindy,

Please read below different scenarios to bill colonoscopy screening as per diagnosis, incidental finding and no finding.

If it states regular screening, G-code comes to mind. G0121 for regular screen. G0105 for high risk or increased risks such as Z85.038, Z86.010, Z80.0 and Z38.79. If there are any indications of R10.9 or R10.xx, R19.7, K52.29 etc, and nothing is found, I consider these as incidental signs and symptoms and use the screening codes when also indicated. If only the incidental s/s are mentioned, I use 453XX.

Now, if s/s such as K59.00, K62.5, K19.5, which are real indications of a problem, and screening is also listed as indication, I will not use G code. This is a diagnostic procedure billed with 453XX or depending whether physician finds polyp, and remove or bx it, 4538X.

If your pt comes for a screening, regular or high risk, and bx or polypectomy is performed, you would still use the Z code as primary dx and the polyp as 2nd, since this was the original intend. Append modifier Pt or 33 whatever is appropriate for the carrier you billed.  

Also, in more simpler way with some examples see below:

If the surgeon performs a diagnostic colonoscopy for a Medicare beneficiary, you should report the appropriate CPT code that describes procedure, such as 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).

But you should report screening colonoscopies for Medicare beneficiaries using one of the following codes:

  • G0105 (Colorectal cancer screening; colonoscopy on individual at high risk)
  • G0121 ( Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk)

For non-Medicare payers, you’ll report a screening or diagnostic colonoscopy that involves no further intervention using 45378.

Whether for Medicare or non-Medicare payers, if the surgeon finds something during the colonoscopy that results in further intervention, you should use the appropriate CPT code, such as one of the following:

  • 45380 (Colonoscopy, flexible; with biopsy, single or multiple)
  • 45384 ( Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)

Please feel free to ask for any further query.

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