Brush up on Colonoscopy Billing Codes and Guidelines

Colorectal cancer is the third leading cause of cancer-related deaths in the U.S. population, and the second most common cause of cancer deaths when men and women are combined, according to the American Cancer Society (ACS). A diagnostic and therapeutic procedure performed in an outpatient setting, colonoscopy helps physicians effectively screen for colorectal cancer and colorectal polyps, and detect and remove abnormalities of the large intestine. The ACS now recommends that those aged 45 and older get a colonoscopy every 10 years. March is National Colorectal Cancer Awareness Month and the best time for physicians and medical billing companies to brush up on colonoscopy billing codes and guidelines.

Types of Colonoscopies

There are different types of colonoscopies: screening colonoscopies, diagnostic colonoscopies, screening colonoscopies that become diagnostic colonoscopies, incomplete colonoscopies, and surveillance colonoscopies. Coders need to be able to distinguish these types and report the right colonoscopy billing codes.

• Screening colonoscopy – Performed on a person with no symptoms in order to test for the presence of colorectal cancer or colorectal polyps.
• Diagnostic colonoscopy – Performed on a patient with gastrointestinal symptoms (e.g., rectal bleeding, abdominal pain, diarrhea) or who has past and/or present polyps or gastrointestinal disease. The most common aim is to prevent colon cancer.
• Screening colonoscopies that turn into diagnostic colonoscopies -The colonoscopy becomes diagnostic if a polyp or lesion is found during the screening procedure.
• Incomplete colonoscopy – If there is difficulty in advancing the colonoscope through the colon, the colonoscopy is referred to as incomplete’.
• Surveillance colonoscopy – If the patient has a history of colon polyps, polyps, and/or gastrointestinal disease and returns for a follow-up exam, a surveillance colonoscopy is performed. The Bulletin of the American College of Surgeons describes a surveillance colonoscopy as a subset of screening.

CPT Codes for Colonoscopy (45378-45398)

45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

45379 Colonoscopy, flexible; with removal of foreign body(s)

45380 Colonoscopy, flexible; with biopsy, single or multiple

45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance

45382 Colonoscopy, flexible; with control of bleeding, any method

45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and postdilation and guide wire passage, when performed)

45384 Colonoscopy, flexible; with removal of tumor(s), polyp(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

45386 Colonoscopy, flexible; with transendoscopic balloon dilation

45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre- and postdilation and guide wire passage, when performed)

45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures

45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures

45390 Colonoscopy, flexible; with endoscopic mucosal resection

45393 Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed

45398 Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids)

HCPCS Codes for Colonoscopy

HCPCS codes have been developed to differentiate between screening and diagnostic colonoscopies in the Medicare population.

81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result

82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection)

G0104 Colorectal cancer screening; flexible sigmoidoscopy

G0105 Colorectal cancer screening; colonoscopy on individual at high risk

G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema

G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema

G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous

G0464 Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)

Colonoscopy Billing – Some Key Points

Here are some key things to know about colonoscopy billing:

• Failed or “incomplete” colonoscopies should be coded using CPT 45378 with the right G-code modifier for a failed procedure.
• Beginning in 2018, the CPT code for screening colonoscopies was updated to CPT code 00812, describing anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum (Beckers ASC Review).
• When a screening colonoscopy becomes a diagnostic colonoscopy, append PT modifier (Colorectal cancer screening test; converted to diagnostic test or other procedure) to anesthesia code 00810, says the American College of Obstetricians and Gynecologists (ACOG).
• Beckers ASC Review cites Stephanie Ellis, president of Ellis Medical Consulting on bleeding control. According to Ellis, bleeding control is included in biopsy and most other endoscopic procedures and is not separately billable unless “the patient arrives at the center with a GI bleed as the reason for a procedure being performed”.
• On screening colonoscopy, the American Gastroenterological Association clarifies that CPT code 45378 should be used for commercial and Medicaid patients. For Medicare beneficiaries, 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) should be used.
• The 2018 CPT code book introduced 2 new codes to report anesthesia during colonoscopy:
• 00811     Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified
• 00812    Screening colonoscopy

According to CPT guidelines, 00812 should be reported to describe anesthesia for any screening colonoscopy regardless of ultimate findings, that is, if an exam begins as a screening, but the colonoscopy reveals a polyp(s) or other diagnostic finding, anesthesia service should be reported as a screening.

Gastroenterology medical billing and coding is much easier with assistance from an expert. Experienced medical billing service providers can help practices report procedures, tests and visits correctly and obtain fair and reasonable reimbursement.