Full Answer
The CPT® codebook, in contrast to CMS rules, instructs, "For an incomplete colonoscopy, with full preparation for a colonoscopy, use a colonoscopy code with the modifier 52 and provide documentation." Some non-Medicare payers may follow CMS guidelines for an incomplete colonoscopy, while others may adhere to CPT®
report an incomplete colonoscopy with 45378 and append modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy. In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states,
When coding colonoscopies a complete colonoscopy must reach the cecum, in this case it's incomplete which results in modifier 52. When using modifier 53 in colonoscopies it should be used when the procedure is aborted for incomplete prep or questionable health status of the patient.
for diagnostic colonoscopy, CPT code 45378, decreased 9 percent, from 3.69 to 3.36. The colonoscopy code set still includes moderate sedation. Therefore, the endoscopist may not report an additional code for supervision of moderate sedation (99143– 99150) or anesthesia (00740 or 00810). A second physician, other than the one performing
Article - Billing and Coding: Incomplete Colonoscopy/Failed Colonoscopy (A55227)
Z12. 11 encounter for screening for malignant neoplasm of colon.
Z12. 11 (encounter for screening for malignant neoplasm of colon) Z80. 0 (family history of malignant neoplasm of digestive organs)...Two Sets of Procedure Codes Used for Screening Colonoscopy:Common colorectal screening diagnosis codesICD-10-CMDescriptionZ86.010Personal history of colonic polyps2 more rows•Apr 20, 2022
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.
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).
ICD-10 code Z12. 39 for Encounter for other screening for malignant neoplasm of breast is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
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.
To report screening colonoscopy on a patient not considered high risk for colorectal cancer, use HCPCS code G0121 and diagnosis code V76. 51 (Special screening for malignant neoplasm of the colon).
“Code Z86. 010, Personal history of colonic polyps, should be assigned when 'history of colon polyps' is documented by the provider. History of colon polyp specifically indexes to code Z86.
ICD-10 code Z12. 12 for Encounter for screening for malignant neoplasm of rectum is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
The colonoscopy or sigmoidoscopy is still classified as a preventive service eligible for coverage at the no-member-cost-share benefit level. a. Submit the claim with Z12. 11 (Encounter for screening for malignant neoplasm of colon) as the first-listed diagnosis code; this is the reason for the service or encounter.
CPT code 45378 is currently assigned to ASC payment group 2. Code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) has been added to the ASC list effective for services furnished on or after January 1, 1998.
Prior to 2015, CPT® defined “incomplete colonoscopy” as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon).
New payment rates will apply when modifier 53 Discontinued procedure is appended to CPT®/HCPCS Level II codes:
The initial exam would have been reported G0105-53, for which the physician should receive reimbursement equivalent to that of a flexible sigmoidoscopy. For the second, successful exam, report G0105 once again, this time without a modifier.
Medicare rules for coding colonoscopy differ from American Medical Association (AMA) rules, particularly with regard to “incomplete” colonoscopies. For a Medicare patient undergoing a screening colonoscopy, if the surgeon is able to advance the scope past the splenic flexure, consider the colonoscopy “ complete” and report the appropriate code ...
Reporting an incomplete screening should not trigger Medicare frequency limitations or affect your ability to collect appropriate reimbursement for a subsequent complete examination. “It is not appropriate to count the incomplete colonoscopy toward the beneficiary’s frequency limit for a screening colonoscopy because that would preclude ...
To report screening colonoscopy on a patient not considered high risk for colorectal cancer, use HCPCS code G0121 and diagnosis code Z12.11 ( encounter for screening for malignant neoplasm of the colon ).
As such, “screening” describes a colonoscopy that is routinely performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not ...
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) G0121 ( colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk.
Typically, procedure codes with 0, 10 or 90-day global periods include pre-work, intraoperative work, and post-operative work in the Relative Value Units (RVUs) assigned . As a result, CMS’ policy does not allow for payment of an Evaluation and Management (E/M) service prior to a screening colonoscopy. In 2005, the Medicare carrier in Rhode Island explained the policy this way:
Diagnosis Code Ordering is Important for a Screening Procedure turned Diagnostic. When the intent of a visit is screening, and findings result in a diagnostic or therapeutic service, the ordering of the diagnosis codes can affect how payers process the claim.
Screening colonoscopy is a service with first dollar coverage. A screening test with an A or B rating from the US Preventive Services Task Force, should have no patient due amount, since the Affordable Care Act (ACA) was passed.
The patient has never had a screening colonoscopy. The patient has no history of polyps and none of the patient’s siblings, parents or children has a history of polyps or colon cancer. The patient is eligible for a screening colonoscopy. Reportable procedure and diagnoses include:
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Title XVIII of the Social Security Act, §1833 (e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Virtual Colonoscopy (CT Colonography) L33452.
Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in the related LCD have been met.
All other ICD-10 codes not listed under ICD-10-CM Codes that Support Medical Necessity will be denied as not medically necessary.
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Title XVIII of the Social Security Act, §1862 (a) (1) (A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Indications Computed Tomography (CT) colonography, also known as virtual colonoscopy, utilizes helical CT of the abdomen and pelvis along with 2D or 3D reconstruction to visualize the colon lumen.
Those patients in whom a standard (fiberoptic, video) colonoscopy of the entire colon is incomplete due to an inability to pass the colonoscope proximally. Failure to advance the colonoscope may be secondary to an obstructing neoplasm, spasm, redundant colon, diverticulitis, extrinsic compression or aberrant anatomy/scarring from prior surgery.
CT colonography may also be medically reasonable and necessary for those patients in whom a standard colonoscopy is contraindicated. The following are considered contraindications to standard colonoscopy, and therefore covered indications for CT colonography: Coagulopathy. Lifetime anticoagulation or long-term anticoagulation therapy ...
CT colonography is not reimbursable when used as an alternative to standard diagnostic colonoscopy, except as noted above, since current literature does not yet support the relative effectiveness of this modality. CT colonography would not be expected to be performed when there is either a known or strongly expected need for biopsy.
CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, MA, CPC. Mr. Verhovshek is the managing editor for AAPC, a training and credentialing association for the business side of health care.
Medicare rules for coding colonoscopy differ from American Medical Association (AMA) rules, particularly with regard to “incomplete” colonoscopies. For a Medicare patient undergoing a screening colonoscopy, if the surgeon is able to advance the scope past the splenic flexure, consider the colonoscopy “ complete” and report the appropriate code ...
Reporting an incomplete screening should not trigger Medicare frequency limitations or affect your ability to collect appropriate reimbursement for a subsequent complete examination. “It is not appropriate to count the incomplete colonoscopy toward the beneficiary’s frequency limit for a screening colonoscopy because that would preclude ...