Frequently Asked Coding Questions
QUESTION: One of the most confusing aspects of gastroenterology billing is submitting claims for screening colonoscopy. Can you explain the differences between average risk and high risk screening?
ANSWER: Commercial payors may decide to follow Medicare policy on colorectal cancer (CRC) screening or use their own definitions on coverage policies and benefits, which can make billing screening colonoscopies more difficult. Listed below are the definitions of average and high risk, and some associated billing tips.
Average risk screening: Lack of symptoms and abnormalities
• Medicare: G0121
• Commercial, Medicaid, exchange/marketplace, Tricare: 45378 with the appropriate ICD-9 (through Sept. 30, 2015) or ICD-10 code (effective Oct. 1, 2015) for screening:
ICD-9 codes for colorectal cancer screening: V16.0, V18.51, V18.59, V70.0, V76.41, V76.50, V76.51
ICD-10 codes for colorectal cancer screening: Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.71, Z83.79
What happens when a lesion is found during a screening colonoscopy?
During a screening colonoscopy, polyps or other lesions can be found which are biopsied or removed. The procedure is now considered a “surgical colonoscopy,” often increasing the patient’s financial responsibility, even though the intent was screening.
• For commercial payors, add modifier 33 to the surgical claim, which informs the payor that the intent of the colonoscopy was a preventive service. If billed with screening as the principal diagnosis and the finding as the secondary diagnosis, many commercial payors will continue to pay preventive benefits.
• For Medicare, add modifier PT to the surgical claim, which informs Medicare that the intent of the colonoscopy was a preventive service. Modifier PT waives the patient’s deductible, but the patient is now responsible for the 20 percent co-pay.
Effective Jan. 1, 2015, anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a colorectal cancer screening test should include the 33 modifier on the claim line with the anesthesia service.
In situations that begin as a colorectal cancer screening test, but for which another service, such as colonoscopy with polyp removal, is actually furnished, the anesthesia professional should report a PT modifier on the claim line rather than the 33 modifier. The patient is now responsible for the 20 percent co-pay for the anesthesia service.
QUESTION: One of the most confusing aspects of gastroenterology billing is submitting claims for screening colonoscopy. Can you explain the differences between average risk and high risk screening?
ANSWER: Commercial payors may decide to follow Medicare policy on colorectal cancer (CRC) screening or use their own definitions on coverage policies and benefits, which can make billing screening colonoscopies more difficult. Listed below are the definitions of average and high risk, and some associated billing tips.
Average risk screening: Lack of symptoms and abnormalities
- Screening, by definition, is a service performed on a patient in the absence of signs and symptoms.
- Medicare’s definition of average risk is no personal history of adenomatous polyps, colorectal cancer or inflammatory bowel disease, including Crohn’s disease and ulcerative colitis; no family history of colorectal cancers or an adenomatous polyp, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.
- For most payors, a patient is eligible for screening colonoscopy on or after age 50. Some payors allow for screening to begin at age 45 for patients of certain gender and/or ethnic origin. If there are questions, check the summary of plan documents (SPD) and/or the plan’s coverage policies.
- Since Jan. 1, 2011, Medicare waives the co-pay and deductible for the professional and facility fees for screening colonoscopy at 100 percent with no patient financial responsibility.
- In the final rule for 2015, Medicare expanded the waiver of co-pay and deductible to include anesthesia for screening colonoscopy. A -33 modifier should be added to the 00810 anesthesia code to indicate the circumstance was preventive. This coverage “trumps” local contractor medical necessity policies now in existence in a screening circumstance. In the circumstance when a screening procedure becomes therapeutic (see next bullet), the PT modifier should be applied to the anesthesia service. A copay will still apply, but the deductible should be waived.
- If the screening colonoscopy is negative, a follow-up procedure is allowed every 10 years by Medicare. The frequency for follow-up for commercial payors is dependent upon the patient coverage/plan, but most follow either CMS policy or the U.S. Multi-Specialty Task Force (MSTF) recommendations.
- Billing for a screening colonoscopy in an average risk patient:
• Medicare: G0121
• Commercial, Medicaid, exchange/marketplace, Tricare: 45378 with the appropriate ICD-9 (through Sept. 30, 2015) or ICD-10 code (effective Oct. 1, 2015) for screening:
ICD-9 codes for colorectal cancer screening: V16.0, V18.51, V18.59, V70.0, V76.41, V76.50, V76.51
ICD-10 codes for colorectal cancer screening: Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.71, Z83.79
What happens when a lesion is found during a screening colonoscopy?
During a screening colonoscopy, polyps or other lesions can be found which are biopsied or removed. The procedure is now considered a “surgical colonoscopy,” often increasing the patient’s financial responsibility, even though the intent was screening.
• For commercial payors, add modifier 33 to the surgical claim, which informs the payor that the intent of the colonoscopy was a preventive service. If billed with screening as the principal diagnosis and the finding as the secondary diagnosis, many commercial payors will continue to pay preventive benefits.
• For Medicare, add modifier PT to the surgical claim, which informs Medicare that the intent of the colonoscopy was a preventive service. Modifier PT waives the patient’s deductible, but the patient is now responsible for the 20 percent co-pay.
Effective Jan. 1, 2015, anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a colorectal cancer screening test should include the 33 modifier on the claim line with the anesthesia service.
In situations that begin as a colorectal cancer screening test, but for which another service, such as colonoscopy with polyp removal, is actually furnished, the anesthesia professional should report a PT modifier on the claim line rather than the 33 modifier. The patient is now responsible for the 20 percent co-pay for the anesthesia service.