Colonoscopy Billing tips - cpt 45380 & 45385

As a speaker at many national conferences, I find the question most frequently asked is, “What is the proper way to code a screening colonoscopy?” First, let’s talk about what is a screening colonoscopy. Physicians suggest a colorectal cancer screening (colonoscopy) typically when a healthy patient turns age 50. The procedure entails a colonoscope inserted in the anus moved through the colon past the splenic flexure in order to visualize the lumen of the rectum and the colon. It is used to provide an early diagnosis of colorectal cancer, diverticulosis, ulcerative colitis, Crohn’s disease, etc. The diagnosis code for the screening is selected from the V code section V76.51 (Special screening for malignant neoplasms, colon). The CPT code would be 45378 (Colonoscopy, flexible, proximal to splenic flexure, diagnostic).

Polypectomies

If during the screening a polyp is discovered and a polypectomy is performed, the ICD-9 coding sequence would be V76.51 as your primary diagnosis, and the polyp or abnormality as secondary. When choosing the procedure code, look at the technique used to remove the polyps. (Note: This is not all-inclusive list; please see the current edition of CPT for a complete list of polypectomy codes). Here are some examples:

• 45380—Colonoscopy, with biopsy, single or multiple. Hint: The physician may use the words “biopsy forceps,” or “Jumbo forceps.”
• 45385—Colonoscopy, with removal of tumor(s), polyp(s), lesion(s) by snare technique. Hint: This code covers both cold and hot snare.

Regardless of how many polyps are removed, you may only use each of these codes once.

Medicare Screenings

Medicare has slightly different code selections for colorectal screenings. Let’s talk about the ICD-9 code selections. For a Medicare patient, you would report V76.51 as the primary diagnosis. Then you must check if the patient is considered a high risk. There are specific criteria that CMS requires for a patient to be categorized as “high risk.” To establish the patient as “high risk,” the patient should exhibit one or more of the conditions found on the CMS list, which you should report as a secondary diagnosis to V76.51. Here are some examples:

• V10.05—Personal history of malignant neoplasm, large intestine
• V12.72—Personal history of colonic polyps
• 556.0—Ulcerative (chronic) enterocolitis

NOTE: This is not all-inclusive. Please review the complete list at http://www.cms.hhs.gov/ as well as local carriers, as they may have specific requirements. As a facility coder, it is advised that you check the patient’s chart, specifically the history and physical as well as the operative report, to ensure proper documentation supports the criteria. If the patient does not meet any of the criteria, then the patient is considered at average risk for colorectal cancer.
The risk factor will determine the procedure code. You should choose one of the following: orectal cancer screening; colonoscopy for an individual not meeting criterion for high risk (average risk):

• G0105—Colorectal cancer screening; colonoscopy for an individual at high risk.

Incomplete Colonoscopies

For coding purposes, the colonoscope must pass the splenic flexure. If this is not achieved, it is an incomplete colonoscopy. In these instances, you should use the CPT code for the procedure intended and append one of the following modifiers:

• Modifier 73—Discontinued procedure due to extenuating circumstances or those threatening the well being of the patient prior to the administration of anesthesia. The physician may cancel or discontinue the procedure subsequent to the patient’s surgical preparation (including sedation, and being taken to the room where the procedure is to be performed).
• Modifier 74—Discontinued procedure due to extenuating circumstances or those threatening the well being of the patient after the administration of anesthesia, or after the procedure was started.

When using these modifiers, it is important to have supporting documentation that clearly states how far the scope was inserted and the reason for the discontinuation. This information should be sent with the claim form for proper reimbursement.