Screening vs. Diagnostic Colonoscopies
Understanding when a colonoscopy is a screening or diagnostic procedure is critical not only for accurate code selection but also for the billing process since patient benefits vary for each service.
Screening Criteria
The American Cancer Society recommends individuals who are at average risk of colorectal cancer start regular screenings at the age of 45. Average risk means those people who do not have a personal history of colon cancer, polyps, or inflammatory bowel disease or a family history of colorectal cancer. Those who have a personal or family history are considered high risk and may need to begin screening before age 45, depending on history.
Medicare covers an average risk screening colonoscopy once every 10 years, whereas high risk screenings are covered once every 24 months. If the colonoscopy results are normal, there is no cost to the patient for this service. If a polyp or other pathology is found during the encounter and is treated, then the patient may be responsible for a 20% co-insurance and/or a co-pay but would not be responsible for the deductible. For patients with commercial insurance, it’s important to verify screening benefits since they may have specific coverage requirements concerning age and frequency.
The codes for screening include:
Diagnosis
Z12.11 Encounter for screening for malignant neoplasm of colon
Z85.038 Personal history of other malignant neoplasm of large intestine
Z86.010 Personal history of colonic polyps
Z80.0 Family history of malignant neoplasm of digestive organs
Medicare Procedure Codes
G0121 Colorectal cancer screening, colonoscopy on individual not meeting criteria for high risk
G0105 Colorectal cancer screening, colonoscopy on individual at high risk
G0104 Colorectal cancer screening, flexible sigmoidoscopy
Commercial Procedure Codes
45378 Colonoscopy, flexible, diagnostic, including collection of specimen (s) by crushing or washing when performed
45330 Sigmoidoscopy, flexible, diagnostic, including collection of specimen (s) by brushing or washing when performed
If a polyp or other pathology is found and treated, this is considered a screening turned diagnostic procedure and the appropriate CPT code should be used based on the technique(s) with a modifier PT(colorectal cancer screening test, converted to diagnostic test or other procedure.) added for Medicare and a 33 (preventative service) for commercial. If multiple methods of removal are used for separate polyps/lesions, then each method can be reported separately. For example, if a sigmoid polyp is removed using hot biopsy forceps and a rectal polyp removed via snare, 45384 and 45385 would be reported. Each technique is only reported once per encounter, even if multiple polyps/lesions were removed using that technique.
Common Diagnostic/Therapeutic Procedure Codes
45380 Colonoscopy, flexible, with biopsy, single or multiple
45381 Colonoscopy, flexible, with directed submucosal injection, any substance
45382 Colonoscopy, flexible with control of bleeding, any method
45384 Colonoscopy, flexible, with removal of tumor(s), polyps(s), or other lesion(s) by hot biopsy forceps
45385 Colonoscopy, flexible, with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45388 Colonoscopy, flexible, with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre and post dilation and guide wire passage when performed
45390 Colonoscopy, flexible, with endoscopic mucosal resection
Diagnostic
When a patient presents for a colonoscopy due to a gastrointestinal issue, then this becomes a diagnostic procedure. Even if the patient qualifies for a screening, a screening can not be coded if they have symptoms. The coder should code the symptoms or applicable findings and any interventions performed.
Positive Cologuard
Cologuard tests are commonly used as part of the colorectal cancer screening process as a less invasive alternative to a colonoscopy. These test detect alterations in a patient’s DNA associated with colon cancer and precancerous polyps. If a patient has a positive Cologuard test, a colonoscopy is necessary as a next step to survey for these lesions. The subsequent test following a positive Cologuard test are considered diagnostic, not screening. When a patient undergoes colonoscopy for a positive Cologuard test and there are not abnormal findings, the coder would report the diagnosis as R19.5 (other fecal abnormalities.). If the patient undergoes a colonoscopy for a positive Cologuard and a polyp is found, the coder would select K63.5 (polyp of colon) as the first listed diagnosis for the colonoscopy.
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