Common colorectal screening diagnosis codes | |
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ICD-10-CM | Description |
Z12.11 | Encounter for screening for malignant neoplasm of colon |
Z80.0 | Family history of malignant neoplasm of digestive organs |
Z86.010 | Personal history of colonic polyps |
When not to have a colonoscopy Small polyps grow slowly and may take ten years or longer (if at all) to develop into bowel cancer. This is why it is considered inappropriate to continue screening...
What is the difference between a “screening” colonoscopy and a “diagnostic” colonoscopy? A “screening” colonoscopy is a colonoscopy that is done for the prevention of colorectal cancer and is considered a preventive health service. A screening colonoscopy will have no out-of-pocket costs for patients (such as co-pays or deductibles).
Two Sets of Procedure Codes Used for Screening Colonoscopy: CPT® code 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen (s) by brushing or washing, with or without colon decompression (separate procedure) and Healthcare Common Procedural Coding System (HCPCS) codes G0105 and G0121
Guidelines for Surveillance Colonoscopy. Routine baseline colonoscopy with good to excellent prep; no precancerous polyps, no significant family history or advanced polyps: Interval to next exam is 10 years. Small rectal hyperplastic polyps: Colonoscopy or other screening options at intervals recommended for average-risk individuals.
A screening colonoscopy should be reported with the following International Classification of Diseases, 10th edition (ICD-10) codes: Z12. 11: Encounter for screening for malignant neoplasm of the colon.
If the patient presents for a screening colonoscopy and a polyp or any other lesion/diagnosis is found, the primary diagnosis is still going to be Z12. 11, Encounter for screening for malignant neoplasm of colon. The coder should also report the polyp or findings as additional diagnosis codes.
ICD-10 code Z12. 83 for Encounter for screening for malignant neoplasm of skin is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
Z12. 11 Encounter for screening for malignant neoplasm of colon - ICD-10-CM Diagnosis Codes.
For example, Z12. 31 (Encounter for screening mammogram for malignant neoplasm of breast) is the correct code to use when you are ordering a routine mammogram for a patient. However, coders are coming across many routine mammogram orders that use Z12. 39 (Encounter for other screening for malignant neoplasm of breast).
Z12. 12 Encounter for screening for malignant neoplasm of rectum - ICD-10-CM Diagnosis Codes.
The code Z12. 83 (encounter for screening for malignant neoplasm of skin) will now be the best code for these purposes.
Z12. 83 - Encounter for screening for malignant neoplasm of skin | ICD-10-CM.
9: Disorder of bone density and structure, unspecified.
An exam can be reported as a surveillance colonoscopy is the patient has a history of polyps, is now returning for a follow-up exam and is otherwise asymptomatic. Code Z86. 010 (Personal history of colonic polyps) should be reported if the previous polyps were benign.
Group 1CodeDescription45378COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)45379COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)45380COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE22 more rows
A screening colonoscopy will have no out-of-pocket costs for patients (such as co-pays or deductibles). A “diagnostic” colonoscopy is a colonoscopy that is done to investigate abnormal symptoms, tests, prior conditions or family history.
A malignant tumor at the original site of growth. [ from NCI]
The term "malignant neoplasm" means that a tumor is cancerous. A doctor may suspect this diagnosis based on observation — such as during a colonoscopy — but usually a biopsy of the lesion or mass is needed to tell for sure whether it is malignant or benign (not cancerous).
ICD-10 Code for Encounter for screening for malignant neoplasm of prostate- Z12. 5- Codify by AAPC.
Z00.00ICD-10 Code for Encounter for general adult medical examination without abnormal findings- Z00. 00- Codify by AAPC.
The 2022 edition of ICD-10-CM Z12.11 became effective on October 1, 2021.
Screening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the disease. Type 1 Excludes. encounter for diagnostic examination-code to sign or symptom. Use Additional.
In this case, since the word SURVEILLANCE colonoscopy is documented, I would recommend coding this as a screening (Z12.11), followed by any findings, as well as the personal history of colonic polyps (Z86.010) – sequenced in that order.
Remember that once the polyp is removed the patient follow up visits should not be code with K63.5, polyp of colon. Then, use code Z86.010, personal history of colonic polyps.
A screening code may be a first-listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems. A screening code is not necessary if the screening is inherent to a routine examination, such as a pap smear done during a routine pelvic examination.
A screening mammogram is an example of such a test. If a screening examination identifies pathology, the code for the reason the test (namely, the screening code from categories Z11-Z13) is assigned as the principle diagnosis or first-listed code, followed by a code for the pathology or condition found during the screening exam.”.
I 21 c Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram).
In these cases, the sign or symptom is used to explain the reason for the test.
A: Of note, if there is only a diagnosis of FAMILY history of colon cancer and nothing else is documented, these are coded as a screening (even if the physician doesn’t document screening). This is based on a Coding Clinic, 1999, 1st qtr. page 4.
Screening colonoscopies can occur before the age of 50 if there is a family history of colon cancer or polyps.
A screening colonoscopy is performed once every 10 years on healthy individuals while a surveillance colonoscopy is usually performed every two to five years and is based on the outcome of an individual’s previous colonoscopy.
Coding colonoscopies can be one of the more difficult procedures to code in the ASC setting if you don’t have a firm understanding of rules and regulations surrounding these types of cases. Let’s take a look at some of the more common scenarios and how to apply proper coding.
Informs Medicare that service performed was for a screening and does not charge a co-pay or deductible to the patient
Patients with a history of colon polyps are not recommend for a screening colonoscopy, but for a surveillance. Here are a few scenarios where the patient is followed by a surveillance regimen: Patient’s personal or family history of GI Cancer. Type, amount and size of polyp (s)
The 2022 edition of ICD-10-CM Z13.820 became effective on October 1, 2021.
Screening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the disease. Type 1 Excludes. encounter for diagnostic examination-code to sign or symptom. Encounter for screening for other diseases and disorders.
For Medicare beneficiaries, screening colonoscopy is reported using the following HCPCS codes: - G0105 (Colorectal cancer screening; colonoscopy on individual at high risk), for a Medicare beneficiary at high risk for colorectal cancer, and the appropriate diagnosis code that necessitates the more frequent screening.
Point to note: Code 45378 is the base code for a colonoscopy without biopsy or other interventions. It includes brushings or washings if performed. Report 45378 with ICD-10 code Z86.010 on the first line of the CMS 1500 form.
Medicare beneficiaries without high-risk factors are eligible for a screening colonoscopy every ten years. Beneficiaries at higher risk for developing colorectal cancer are eligible for screening once every 24 months. Medicare considers an individual who is at high risk of developing colorectal cancer as one who has one or more of the following:
According to a study by the American Cancer Society, 90% colorectal cancer (CRC) cases are detected in individuals with over 50 years in the U.S and colonoscopy is the most effective and the most commonly adopted procedure for the diagnosis and screening of CRC in older adults.
A Screening colonoscopy is performed on person without symptoms in order to test for the presence of colorectal cancer or colorectal polyps. Even if a polyp or cancer is found during a screening exam, it does not change the screening intent.
CPT defines a colonoscopy examination as "the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include an examination of the terminal ileum or small intestine proximal to an anastomosis" as well.
33 - Modifier 33 modifier should be appended for preventive services when the primary purpose of the service is the delivery of an evidence-based service.
Billing and Coding articles provide guidance for the related Local Coverage Determination (LCD) and assist providers in submitting correct claims for payment. Billing and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes. The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered.
Note: Z80.0 does not appear as a covered ICD-10 code in the Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy A56632 article because the Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy L34454 LCD addresses ONLY procedures performed for diagnostic and/or therapeutic purposes. LCD L34454 and Article A56632 do not address criteria for the performance of or coding for screening procedures or screening procedures that are converted to diagnostic/therapeutic procedures based upon unanticipated pathology encountered during the visualization of the colon.
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Preventive Services Task Force (USPSTF):#N#A screening colonoscopy is performed once every 10 years for asymptomatic patients aged 50-75 with no history of colon cancer, polyps, and/or gastrointestinal disease.#N#A surveillance colonoscopy can be performed at varying ages and intervals based on the patient’s personal history of colon cancer, polyps, and/or gastrointestinal disease. Patients with a history of colon polyp (s) are not recommended for a screening colonoscopy, but for a surveillance colonoscopy. Per the USPSTF, “When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.”#N#The USPSTF does not recommend a particular surveillance regime for patients who have a personal history of polyps and/or cancer; however, surveillance colonoscopies generally are performed in shortened intervals of two to five years. Medical societies, such as the American Society of Colon and Rectal Surgeons and the American Society of Gastrointestinal Endoscopy, regularly publish recommendations for colonoscopy surveillance.#N#The type of colonoscopy will fall into one of three categories, depending on why the patient is undergoing the procedure.#N#Diagnostic/Therapeutic colonoscopy (CPT® 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen (s) by brushing or washing, with or without colon decompression (separate procedure))#N#Patient has a gastrointestinal sign, symptom (s), and/or diagnosis.#N#Preventive colonoscopy screening (CPT® 45378, G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)#N#Patient is 50 years of age or older#N#Patient does not have any gastrointestinal sign, symptom (s), and/or relevant diagnosis#N#Patient does not have any personal history of colon cancer, polyps, and/or gastrointestinal disease#N#Patient may have a family history of gastrointestinal sign, symptom (s), and/or relevant diagnosis#N#Exception: Medicare patients with a family history (first degree relative with colorectal and/or adenomatous cancer) may qualify as “high risk.” Colonoscopy for these patients would not be a “surveillance,” but a screening, reported with HCPCS Level II code G0105 Colorectal cancer screening; colonoscopy on individual at high risk.#N#Surveillance colonoscopy (CPT® 45378, G0105)#N#Patient does not have any gastrointestinal sign, symptom (s), and/or relevant diagnosis.#N#Patient has a personal history of colon cancer, polyps, and/or gastrointestinal disease.
Medical societies, such as the American Society of Colon and Rectal Surgeons and the American Society of Gastrointestinal Endoscopy, regularly publish recommendations for colonoscopy surveillance. The type of colonoscopy will fall into one of three categories, depending on why the patient is undergoing the procedure.
To avoid angry, confused patients, educate them about the types of colonoscopy (preventative, surveillance, or diagnostic) and insurance benefits associated with each procedure . Accomplish this by providing the patient with the correct tools.
According to ICD-9-CM Official Guidelines for Coding and Reporting, section 18.d.4:#N#There are two types of history V codes, personal and family . Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure.#N#Common personal history codes used with colonoscopy are V12.72 and V10.0x Personal history of malignant neoplasm of the gastrointestinal tract. The family history codes include V16.0 Family history of malignant neoplasm of the gastrointestinal tract; V18.51 Family history of colonic polyps; and V18.59 Family history of other digestive disorders. Lastly, V76.51 describes screening of the colon.#N#Per the ICD-9-CM official guidelines, you would be able to report V76.51 (screening) primary to V16.0 (family history of colon polyps). In contrast, you would not use V76.51 (screening) with V12.72 (personal history of colon polyps) because family history codes, not personal history codes, should be paired with screening codes. Personal history would be paired with a follow-up code.#N#Just because you get paid doesn’t mean the coding is correct: Most carriers will pay V76.51 with V12.72 because their edits are flawed and allow it. The patient’s claim will process under a patient’s preventative benefits with no out-of-pocket; however, an audit of the record with the carrier guidance will reveal that the claim incorrectly paid under preventative services when, in fact, the procedure should have paid as surveillance. The best strategy is to contact your payer to be sure you are coding correctly based on that payer’s “screening vs. surveillance” guidelines.
Practices performing colonoscopies for colon and rectal cancer screenings have seen a corresponding rise in requests for “screening” colonoscopy. As a result, there is an increase in incorrectly coded colonoscopies. Practices may not understand that a majority of patients are actually not screening colonoscopies, ...
Colonoscopy for these patients would not be a “ surveillance,” but a screening, reported with HCPCS Level II code G0105 Colorectal cancer screening; colonoscopy on individual at high risk. Patient does not have any gastrointestinal sign, symptom (s), and/or relevant diagnosis.
Under the ACA, payers must offer first-dollar coverage for screening colonoscopy but are not obliged to do so for a surveillance or diagnostic colonoscopy. The patient’s history and findings determine the reason for and type of colonoscopy, driving the benefit determination.
Effective January 1, 2018, anesthesia services furnished in conjunction with and in support of a screening colonoscopy are reported with CPT code 00812 and coinsurance and deductible are waived. When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia services are reported with CPT code 00811 and with the PT modifier; only the deductible is waived.
At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered HCPCS G0121 screening colonoscopy was performed.)
proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), as minimal threshold levels, based on the pivotal studies included in the FDA.
Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was performed)
Effective for dates of service on or after January 19, 2021, a blood-based biomarker test is covered as an appropriate colorectal cancer screening test once every 3 years for Medicare beneficiaries when performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory, when ordered by a treating physician and when all of the following requirements are met:
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Effective January 1, 2015 through December 31, 2017, anesthesia professionals who furnish a separately payable anesthesia service (CPT code 00810) in conjunction with a screening colonoscopy shall include the following on the claim for the services that qualify for the waiver of coinsurance and deductible: