Your colonoscopy is considered a diagnostic colonoscopy for the following reasons:
ICD-10-CM Diagnosis Code Z12.11 [convert to ICD-9-CM] Encounter for screening for malignant neoplasm of colon. Screening for colon cancer; Screening for colon cancer done; Encounter for screening colonoscopy NOS. ICD-10-CM Diagnosis Code Z12.11. Encounter for screening for malignant neoplasm of colon.
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
Diagnostic Colonoscopy. A diagnostic colonoscopy, while basically the same procedure, is used in different situations than a screening colonoscopy. Diagnostic colonoscopies are used when a patient exhibits specific symptoms that may indicate colon cancer or other issues. This procedure helps the physician further diagnose the patient’s condition.
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.
Report Z01. 818 (Encounter for other preprocedural examination) as the first-listed diagnosis code. Since the screening colonoscopy/sigmoidoscopy is not performed at this encounter, Z12. 11 is not an appropriate diagnosis code.
The second claim diagnosis code should be reported with the appropriate preventive/screening ICD diagnosis code (e.g., Z12. 11). CPT code 00812 MUST be used if the screening colonoscopy becomes a diagnostic colonoscopy and/or if the screening colonoscopy is stopped due to poor preparation and a sigmoidoscopy is done.
A family of CPT codes applies to colonoscopy. For example, code 45378 applies to a colonoscopy in which no polyp is detected, while codes 45380-45385 apply to colonoscopy that involves an intervention (e.g., 45385 is the code for colonoscopy with polypectomy.)
For Medicare beneficiaries, use Healthcare Common Procedural Coding System (HCPCS) code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk) as appropriate.
Colonoscopies. Medicare covers screening colonoscopies once every 24 months if you're at high risk for colorectal cancer. If you aren't at high risk, Medicare covers the test once every 120 months, or 48 months after a previous flexible sigmoidoscopy.
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).
Medicare covers a screening colonoscopy once every 24 months for people considered high risk,9 defined as having a history or a close relative with a history of colorectal polyps or cancer, a history of polyps, or inflammatory bowel disease like Crohn's disease or ulcerative colitis.
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.
Diagnostic colonoscopy procedures, also known as surveillance or follow-up colonoscopy tests, are different from screening colonoscopies, tests are only advised when there is a greater risk that colon cancer might develop or if there is evidence that colon cancer may be present.
NOTE: 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 code G0121. The code is not covered by Medicare.
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.
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
When reporting the diagnosis code, I would suggest reporting Z12. 11 (encounter for screening for malignant neoplasm of the digestive organs) and Z86. 010 (personal history of colonic polyps) second. The patient will probably need to appeal this to their insurance company.
Medicare has always allowed CPT 45380 with ICD 9 V76. 51 (screening for malignant neoplasm, colon) as screening, but now when we're using the same diagnosis code in ICD 10, Z12. 11, they're denying it for routine.
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 which lacks the necessary information to process the claim.
If during a colonoscopy a pathology is encountered that necessitates an intervention which converts the screening colonoscopy to a diagnostic/therapeutic colonoscopy, the appropriate CPT ® code which includes the –PT modifier for the diagnostic/therapeutic colonoscopy must be submitted with an appropriate diagnosis to justify the procedure such as Z80.0-Family history of malignant neoplasm of digestive organs. 1) Choose the correct CPT ® code which describes the procedure that was attempted..
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.
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.
A screening code may be a first-listed code if the reason for the visit is specifically the screening exam.
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.”.
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. Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.