Podcast Episode 14: Shining Light on Colonoscopy Coding

Episode Summary

This episode discusses the clinical issues, proper coding (using CPT and modifiers), and current payment policies regarding colonoscopies. Unfortunately, because these three aspects are intimately entwined, colonoscopy coding can get quite complex. Hosts Neal Sheth and Dr. Piyush Sheth try to simplify and clarify the concepts behind coding for colonoscopies.

Episode Transcript 

NEAL SHETH: Hello listeners, one quick note before we get to this episode  about colonoscopy coding. At the end of the episode, we are adding a new segment, Q&A, where my dad answers three questions submitted by our podcast listeners. So, stick around till the end.

A Colonoscopy is the gold standard for evaluating the colon, hands down. But, everyone hates colonoscopies…no lets correct that…everyone hates the colonoscopy prep. But without the prep, good visualization of the colon would be impossible. During the actual colonoscopy procedure, patients are sedated so in reality, it should be a good experience.

On the flip side, billing for colonoscopies is one of the most complicated topics in medical billing. You must take into account the type of colonoscopy, what is done during the colonoscopy, and coding and payment structure differences between health insurance providers.

So, dad, why don't you get us started with some background concepts.

PIYUSH SHETH: Well, this topic is huge but to understand coding and billing, you need to understand why we do colonoscopies, the different types of colonoscopies, and how a colonoscopy is performed.

So here are some basics:

Colon polyps are the precursors of colon cancer. Of the three main types of colon polyps, hyperplastic polyps carry no risk for future colon cancer. The other two types of polyps, tubular adenomas and sessile serrated polyps, do carry a risk of future colon cancer if they are not removed. Numerous diseases also present with colon related symptoms, which can include diarrhea, constipation, rectal bleeding, iron deficiency anemia, etc.

The goal of having a Colonoscopy is to screen for those colon polyps which can turn into colon cancer and for diagnostic and therapeutic reasons  if symptoms are present..

A screening colonoscopy is further classified as screening for average risk and screening for high risk. Screening for average risk is for patients who have no symptoms and have no high-risk indications. High risk indications would be if a patient has a personal or family history of colon polyps or colon cancer, or those with a disorder such as inflammatory bowel disease or polyposis syndromes that predisposes to the development of colon cancer.

Current guidelines recommend that patients at average risk have their first colonoscopy at the age of 45 and every 10 years thereafter if no polyps are found. Screening for high risk starts at the same time unless family history suggests otherwise. Future colonoscopies are also performed at a higher frequency than 10 years in most of these high risk categories.

Confused. OK. Let me give some examples.

A person with no high-risk indications and without any colon-related symptoms presents at the age of 45 for his first screening colonoscopy. He is of average risk. He undergoes this screening colonoscopy and a single tubular adenomatous polyp is found.  If no polyp was found, his next colonoscopy would be in 10 years, but a polyp was found and his next colonoscopy should be in 5 years because he is now considered to be in the high-risk category due to the polyp. In 5 years, he has another colonoscopy and no polys are found. He flips back to the average risk category and should get his next colonoscopy in 10 years.

NEAL: So, the personal history of a tubular adenoma on his first colonoscopy doesn't necessarily mean he has to have a colonoscopy every 5 years?

PIYUSH: No. The findings and the risk level at the end of a colonoscopy determine the frequency of the next colonoscopy.

NEAL: OK, but what if the same person had a father who had colon cancer at the age of 56. How would that change our recommendations?

PIYUSH: In that situation, the person has a high-risk indication that will never go away. He is at a genetic risk for colon cancer development. The frequency for colonoscopies when there is a 1st degree relative with a history of colon cancer is every 5 years. It should never be less frequent than that.

NEAL: Alright, I think I understand the screening for colon cancer colonoscopies. What about diagnostic and therapeutic colonoscopies?

PIYUSH: Simply put, these are colonoscopies done for a symptom. Let's say a patient develops rectal bleeding that is severe and requires a blood transfusion. We would worry about colitis, diverticulosis, or even colon cancer.There are no frequency guidelines for diagnostic and therapeutic colonoscopies. They can be performed any time a condition requires it.

NEAL: So why is all this important? At the end of the day, a colonoscopy is the same whether performed as a screening, diagnostic, or therapeutic procedure?

PIYUSH: You are absolutely right but classifying them directly impacts payment structures. Colonoscopies cost money. Imagine if you were that patient whose father had colon cancer. You need a colonoscopy every 5 years, but the cost, copay, and deductible associated with the procedure might make you reluctant to get a colonoscopy that frequently. To make it easier for access for this cancer detection procedure, the Affordable Care Act  mandates that private insurers and Medicare cover fully the cost of the procedure with no patient responsibility of a copay or deductible.

NEAL: That's fantastic news for patients! Is there anything else we need to know about payment structures?

PIYUSH: Yes. There are alternatives to having a colonoscopy for screening for colon cancer. Fecal Occult Blood Test is one such alternative where your stool is tested for the presence of blood. This should be performed every year and a positive test should prompt performing a colonoscopy. The Cologuard test is another stool test that checks for the presence of genetic sequences found in polyps and cancer and it can be performed every 3 years. It should not be done for patients considered highrisk; however, it is being heavily promoted, sometimes inappropriately. Again, a positive result should prompt a colonoscopy. Also, there is about a 15% false positive and false negative rate with the Cologuard test. That means that up to 15% of patients who have a positive test will not have any findings on a colonoscopy. And, up to 15% of patient who have a negative test may have polyps or cancer, which is a disturbingly high percentage. Radiologic tests such as a Barium enema or a Virtual CT colonography can also be done in lieu of a colonoscopy but a finding on the test will require a colonoscopy. All in all, a Colonoscopy is the gold standard and if you can tolerate the bowel prep, it should be the procedure of choice.

Of special note is that recently the definition of a COLONOSCOPY AFTER A POSITIVE FOBT OR COLOGUARD has changed. Previously it was be considered a diagnostic procedure.   However, to encourage patients to get more colonoscopies, Medicare is classifying these as screening colonoscopies and waiving the patient's co-pay and deductible. For now, only Medicare and some private insurance companies are doing this. The reclassification was strictly to change the payment structure to indirectly encourage patients to get colonoscopies.

Here is the final kicker: if a colonoscopy is performed as a screening procedure but a polyp is removed or some tissue biopsied, it is no longer considered screening but is considered diagnostic. In the past, some insurance companies would ask the patient for a copay and deductible and this would lead to patients being even more reluctant to get a screening colonoscopy. However, the US Department of Health and Human Services has clarified that removal of a polyp is an integral part of a screening colonoscopy, and therefore patients with private insurance should not have to pay out-of-pocket for it. This does not apply to Medicare currently. You will be charged the 15% coinsurance and/or a copay (but you don’t have to pay the deductible). Medicare is going to be phasing this copay out over the next few years so that by 2030, there will not be a copay. The bottom line is that you should always check with your insurance before the procedure to determine your benefits and responsibility if a screening colonoscopy turns into a diagnostic colonoscopy.

NEAL: That's so confusing to me.  How do patients deal with this?

PIYUSH: Well, in our practice, we try to educate our patient about this, and not surprisingly some patients are upset when they get a bill when they had assumed that  a screening colonoscopy would be fully paid by insurance.

NEAL: So, this is just the background concepts.  Can you get us started on the coding concepts dad?

PIYUSH: Of course. Let's start with diagnostic coding with ICD codes. These refer to the indication for the colonoscopy. Obviously if someone has a symptom, you code the symptom. Diarrhea would be K59.1 or R19.7, constipation would be K59.01, blood in the stool would be K92.1, etc.  Screening ICD codes use Z-codes. Screening for average risk for colon cancer and rectal cancer would be Z12.11 and Z12.12, respectively. Screening for high-risk indications also employ Z-codes such as Z80.0 Family history of GI tract cancer or Z86.010 Personal history of colon polyps to name a few. A positive Cologuard test or Fecal Occult Blood Test would be coded a R19.5. If you are using multiple ICD diagnostic codes, the Z-codes and R19.5 are always sequenced first, and all other codes follow. Remember to check the official ICD codes list for the most specific code.

For procedure coding using CPT codes and modifiers, I'm going to break it down into coding for Medicare and coding for private insurers. For diagnostic or therapeutic colonoscopies, there is no difference in how you bill Medicare or private insurers.

However, when it comes to screening colonoscopies, Medicare uses G-codes. G0121 for average risk indication or G0105 for high-risk indication if there were no findings. Of special note is that diverticulosis and hemorrhoids are not considered findings. If, however, there are findings such as polyps, cancer, colitis, etc., you would use the appropriate CPT codes with modifier PT.

Private insurers do not use G-codes. They only use the appropriate colonoscopy CPT codes whether or not there are findings. Private insurers do require modifier 33 for all screening colonoscopy indication categories whether or not there are findings.

One final note on procedure coding for colonoscopies relates to the instance where the indication was for a positive Fecal Occult Blood Test or positive Cologuard test as the reason for doing a screening colonoscopy. If there are no findings, you would add modifier KX.

NEAL: Dad, I don’t understand why it’s so complicated!

PIYUSH: I don't know either. Trust me, I wish it was simpler.

NEAL: So that's it. That's how to bill for colonoscopies.

PIYUSH: Not quite.

NEAL: Ha! I should have known better.

PIYUSH: There are special situations to keep in mind and I'll go through some of them.

First,  YOU CANNOT BILL MEDICARE FOR AN E/M SERVICE PRIOR TO A SCREENING COLONOSCOPY. Since the patient is not having any symptoms, the E/M service is considered a preventative service and by law is not billable. The Office of General Counsel has weighed in on this in 2005 for a Medicare carrier in Rhode Island as follows:

“Medicare does not cover an E/M prior to a screening colonoscopy. An item or service must[NS1]  have a defined benefit category in the law to be covered under Medicare. For example, physician services are covered under the Social Security Act. However, it states that no payment may be made for items or services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. In addition, it prohibits payment for routine physical checkups. This prohibits payment for routine screening services, those services furnished in the absence of signs, symptoms, complaints, or personal history of disease or injury. … While the law specifically provides for a screening colonoscopy, it does not also specifically provide for a separate screening visit prior to the procedure. The Office of General Counsel (OGC) was consulted to determine if the Social Security Act could be interpreted to allow separate payment for a pre- procedure screening visit in addition to the screening colonoscopy. The OGC advises that the statute does not provide for such a pre-procedure screening visit.”

Now, from a clinical standpoint, it is simply good practice to see a patient first and perform a thorough history and physical exam, preferably at least a day before a procedure. Unfortunately, Medicare policies state this is not reimbursable. It is for this reason that many Gastroenterology practices see the patient the morning of the colonoscopy instead of in the office prior to the day of the procedure and do not bill for it. Medicare does not pay for E/M services for procedures on the day of service anyway.

So, consider a scenario where a patient does the full bowel prep, then shows up for the procedure the next day where a provider performs a history and physical exam only to realize that the patient has not stopped his anticoagulation medication, leading to cancellation of the procedure. This probably occurs very rarely but should be avoided. In summary, Medicare's policy to not pay providers for pre-procedure evaluation of patients being considered for screening colonoscopy is leading to a change in clinical behaviors. Does this seem right to you?

Second,  CODING FOR COLONOSCOPY WHEN MULTIPLE PROCEDURES ARE PERFORMED. Coding for colonoscopies is based on the technique used. For example, if you removed one polyp or 100 polyps, the CPT code is just 45385. However, if you remove a polyp and biopsy another lesion, you can bill a CPT 45385 for the polypectomy and a 45380 with modifiers 51 and 59 for the lesion biopsy. The 51 modifier designates the lesion biopsy as a secondary procedure and as such, payment will be made at 50% of the fee schedule for the secondary procedure.

Third,  CODING FOR COLONOSCOPY WHEN IT IS ABORTED DUE TO A POOR PREP. This would be coded with ICD code Z53.8 and a modifier 53 would be attached to the CPT code.

Forth,  CODING FOR COLONOSCOPIES THAT DO NOT REACH THE CECUM OR RIGHT COLECTOMY ANASTOMOSIS. In this instance, if the colonoscopy was for a screening or diagnostic indication, append modifier 53. If the colonoscopy was a therapeutic procedure, use modifier 52.

Fifth,  CODING FOR COLONOSCOPIES THAT DO NOT PASS THE SPLENIC FLEXURE. Code using the Flexible Sigmoidoscopy codes, for example 45330 or 45331.

And Finally,  CODING FOR COLONOSCOPY VIA A STOMA has its own codes, Make sure you consult the CPT code book.

NEAL: Alright dad. I'm convinced that coding for colonoscopies is extremely complicated. Let's close out our episode with the promised Q&A.

First question: Is the annual change in the Medicare Conversion Factor the only way that payment for services can be changed?

PIYUSH: Well, there are 2 other ways. The RVU for a service can be changed and the Geographic Cost Indices can be changed. Most providers pay close attention to the conversion factor, and some pay attention to RVUs. Unfortunately, no one really pays attention to the Geographic cost indices which are updated usually every 5 years. For a discussion on these topics, please listen to Episode 11 on RVUs.

NEAL: Second question: If there was only one thing that you could change in EPIC’s EMR, what would it be?

PIYUSH: Considering that there are a lot of things I would like changed, the one thing that would have the most impact for healthcare providers would be to make EPIC more user friendly and user pertinent. It is a complex beast, and most healthcare providers are frustrated with how unwieldy it can be. If the EPIC end use experience could be improved, it could help prevent providers from cutting corners and making errors.

NEAL: The third and final question dad: There is some discussion that Medicare wants to do away with surgical global periods. Is this a good thing?

PIYUSH: Probably not. Currently, most major surgeries have a 90-day global period and minor surgeries have a 0-day or 10-day global period. The payment for the surgery includes payment for post-op care during the global period. If a surgery is made 0-day global period and the payment for the surgery is diminished so that payment can be made for post-op visits, I feel this opens up a can of worms. First of all, providers may elect to see patients more times than usual during a post-op period and bill for additional services. Healthcare costs will rise. This year, Medicare converted Anterior Abdominal Wall hernia repairs from a 90-day global period to a 0-day global period surgery. They will be collecting data on how many post-op visits are charged to gauge overall reimbursement. Time will tell.

NEAL: That’s it for this episode. Please check out the other episodes. Don’t forget to rate and review us and subscribe to Unraveling Medical Coding from wherever you get your podcasts. Also, please share this podcast with friends or colleagues who you feel would benefit from learning about medical coding and documentation. Stay safe and stay healthy.