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8/19/2019 Keep Your Screening Colonoscopy on Track With These Tips
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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com
Keep Your Screening Colonoscopy on Track
With These TipsBy Susan Dooley
As you probably know, Medicare patients without a high risk of colon cancer are entitled to a screening
colonoscopy every 10 years, assuming they are asymptomatic. Asymptomatic Medicare patients at high
risk are eligible for a screening once every 24 months. The advantage of screening procedures for
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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com
Medicare patients is that they come without “cost sharing” by the patient — which means the patient is
responsible for no copay or deductible cost for the colonoscopy procedure itself.
Whether a procedure is considered to be screening for Medicare’s purposes depends on the situation of
the person having the test, not on the results or findings of the test. For this reason, a screening
colonoscopy is defined as a procedure that is routinely performed on an asymptomatic person to
determine whether colon cancer or polyps are present.
For screening colonoscopy procedures for Medicare patients, report the appropriate screening HCPCS G
code, such as G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and G0121
(Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).
When is a Screening Not a Screening?
But what if during the screening procedure, the gastroenterologist finds and removes a polyp, or decides
she needs to biopsy a suspicious-appearing patch of colonic mucosa? It gets tricky for Medicare claims
when there’s a finding on a screening colonoscopy that requires biopsy or excision. In these cases, while
the diagnosis is still a screening one, since that was the reason for the procedure in the first place, the
procedure itself is no longer considered a screening.
When a colonoscopy on a Medicare patient suddenly switches from screening to needing a biopsy or
polypectomy, you can’t report the procedure with a G code. Instead, you’ll need a CPT® code such as
45380 (Colonoscopy, flexible; with biopsy, single or multiple).
Don’t ZZZ Off on the Z Code With Screening Colonoscopy
Don’t f orget the diagnosis code! Medicare makes it clear that if a patient presents for a screening
colonoscopy, you must report an ICD-10-CM Z code such as Z12.11 (Encounter for screening for
malignant neoplasm of colon; Encounter for screening colonoscopy NOS) as the primary diagnosis in Box
21 of the CMS-1500 claim form. That’s the case even if you can’t report a screening procedure because a
biopsy or polypectomy was needed.
If your provider did perform a polypectomy, turning the screening procedure into a therapeutic one,
you’ll want to make sure you adequately describe the medical necessity for the removal by reporting an
appropriate polyp diagnosis code (D12.-, Benign neoplasm of colon, rectum, anus and anal canal) in
addition to the screening code. (You’d report an appropriate diagnosis code for a biopsy, also.) To make
the proper choice among the D12.- codes, your documentation must specify the polyp’s location, such
as anus, rectum, sigmoid, descending, etc.
Got GI Endoscopy Coding Tips?
Have you had particular success with certain scenarios of GI endoscopy coding? Let us know. We love to
hear from you!
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8/19/2019 Keep Your Screening Colonoscopy on Track With These Tips
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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com
Gastroenterology Coder Puts You in the Speed-Coding Driver’s Seat!
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Enterprise Contact Person:
Name: Sam Nair
Title: Associate Director Enterprise Practice
Email: shyamn@codinginstitute.com
Direct: 704 303 8150
Desk: 866 228 9252, Ext: 4813
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713
mailto:shyamn@codinginstitute.commailto:shyamn@codinginstitute.commailto:shyamn@codinginstitute.commailto:shyamn@codinginstitute.commailto:shyamn@codinginstitute.commailto:shyamn@codinginstitute.commailto:shyamn@codinginstitute.commailto:shyamn@codinginstitute.commailto:shyamn@codinginstitute.commailto:shyamn@codinginstitute.comRecommended