Thursday 30 August 2012

CPT FLEXIBLE SIGMOIDOSCOPY - 45330, 45331

FLEXIBLE SIGMOIDOSCOPY - Procedure

Most used CPT List:
45330
Flexible sigmoidoscopy
45331
Flexible sigmoidoscopy with biopsy
45334
Flexible sigmoidoscopy with control of bleeding/argon laser coagulatioin
45338
Flexible sigmoidoscopy with removal of polyp


Definitions:

Sigmoidoscopy is the examination of the entire rectum and sigmoid colon, and includes examination of a portion of the descending colon.

Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum.

Indications and Limitations of Coverage and/or Medical Necessity

The following are Medicare-covered indications for diagnostic colonoscopy:
Evaluation of an abnormality on barium enema or other imaging study, which is likely to be clinically significant, such as filling a defect or stricture.

Evaluation of unexplained gastrointestinal bleeding:
Hematochezia not thought to be from rectum or perianal source,

Melena of unknown origin; after an upper GI source has been excluded,

Presence of fecal occult blood.

Unexplained iron deficiency anemia.

Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp.

Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management.

Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., with weight loss).

Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source).

Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasm, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).

Removal of foreign body.

Excision of colonic polyps.

Decompression of acute nontoxic megacolon or sigmoid volvulus, pseudo obstruction of the colon (Ogilvie’s syndrome).

Balloon dilatation of stenotic lesions (e.g., anastomotic strictures).

Palliative treatment of stenosing or bleeding neoplasm.

Marking a neoplasm for localization.

Evaluation of a patient with endocarditis due to streptococcus bovis or any bacterium of enteric origin.

Suspected disease of terminal ileum.

Evaluation of acute colonic ischemia/ischemic bowel disease.

In patients with Crohn’s colitis and chronic ulcerative colitis: colonoscopy every one or two years with multiple biopsies for detection of cancer and dysplasia in patients with: 
Pancolitis of eight or more years duration; or

Left-sided colitis of 15 or more years duration.

Evaluation within 6 months of the removal of sessile polyps to determine and document total excision. If evaluation indicates that residual polyp is present, excision should be done with repeat colonoscopy within 6 months. After evidence of total excision without return of the polyp, repeat colonoscopy yearly.

Patients undergoing curative resection for colon or rectal cancer should undergo a colonoscopy 1 year after the resection (or 1 year following the performance of the colonoscopy that was performed to clear the colon of synchronous disease).

A diagnostic colonoscopy is not considered medically necessary for the following conditions:
Chronic, stable, irritable bowel syndrome or chronic abdominal pain. There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy.

Acute limited diarrhea.

Hemorrhoids.

Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management.

Routine follow-up of inflammatory bowel disease (except for cancer surveillance in Crohn's colitis, chronic ulcerative colitis).

Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease.

Upper GI bleeding or melena with a demonstrated upper GI source.

A diagnostic flexible sigmoidoscopy is covered for the following indications:
Evaluation of suspected distal colonic disease when there is no indication for a colonoscopy.

Evaluation for anastomotic recurrence in rectosigmoid carcinoma.

All of the covered indications listed for a diagnostic colonoscopy.

A diagnostic flexible sigmoidoscopy is not indicated when a colonoscopy is indicated.

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients

071x Clinic - Rural Health

085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

032X Radiology - Diagnostic - General Classification

036X Operating Room Services - General Classification

0450 Emergency Room - General Classification

049X Ambulatory Surgical Care - General Classification

051X Clinic - General Classification

052X Freestanding Clinic - General Classification

0750 Gastro-Intestinal (GI) Services - General Classification

076X Specialty Services - General Classification

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

44388 Colonoscopy thru stoma spx

44389 Colonoscopy with biopsy

44390 Colonoscopy for foreign body

44391 Colonoscopy for bleeding

44392 Colonoscopy & polypectomy

44394 Colonoscopy w/snare

44401 Colonoscopy with ablation

44402 Colonoscopy w/stent plcmt

44403 Colonoscopy w/resection

44404 Colonoscopy w/injection

44405 Colonoscopy w/dilation

44406 Colonoscopy w/ultrasound

44407 Colonoscopy w/ndl aspir/bx

44408 Colonoscopy w/decompression

45330 Diagnostic sigmoidoscopy

45331 Sigmoidoscopy and biopsy

45332 Sigmoidoscopy w/fb removal

45333 Sigmoidoscopy & polypectomy

45334 Sigmoidoscopy for bleeding

45335 Sigmoidoscopy w/submuc inj

45337 Sigmoidoscopy & decompress

45338 Sigmoidoscopy w/tumr remove

45340 Sig w/tndsc balloon dilation

45341 Sigmoidoscopy w/ultrasound

45342 Sigmoidoscopy w/us guide bx

45378 Diagnostic colonoscopy

45379 Colonoscopy w/fb removal

45380 Colonoscopy and biopsy

45381 Colonoscopy submucous njx

45382 Colonoscopy w/control bleed

45384 Colonoscopy w/lesion removal

45385 Colonoscopy w/lesion removal

45386 Colonoscopy w/balloon dilat

45391 Colonoscopy w/endoscope us

45392 Colonoscopy w/endoscopic fnb

Flexible Sigmoidoscopy

Specific instructions for reporting flexible sigmoidoscopy have been added to the section guidelines. Report  flexible sigmoidoscopy for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure.

Report flexible sigmoidoscopy for endoscopic examination of a patient who has undergone resection of the colon proximal to the sigmoid (e.g., subtotal colectomy) and has an ileo-sigmoid or ileo-rectal anastomosis. New codes for the flexible sigmoidoscopy family include endoscopic .

CPT Code Short Description Summary of Changes

45330 Flexible sigmoidoscopy Editorial: “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).”

45331 Biopsy Not separately reportable with EMR code 45349 for the same lesion.

45332 Foreign body(s) removal “Foreign body(s)” replaces “foreign body.” 

45333 Hot biopsy Bipolar cautery was deleted as an example.

45334 Control of bleeding “Any method” replaces previous examples. Not separately reportable with injection or banding of hemorrhoids described by 45335, 45350 for same lesion

FLEXIBLE SIGMOIDOSCOPY

45330 45330 Flexible sigmoidoscopy Editorial: “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).”

45331 45331 Biopsy Not reportable with 45349 for the same lesion.

45332 45332 Foreign body removal “Foreign body(s)” replaces “foreign body.” Use 76000 if fluoroscopic guidance is performed.

45333 45333 Hot biopsy Bipolar cautery was deleted as an example.

45334 45334 Control of bleeding “Any method” replaces previous examples. Not separately reportable with injection or banding of hemorrhoids described by 45335, 45350 for same lesion.

45335 45335 Submucosal injection Not separately reportable with control of bleeding or endoscopic mucosal resection described by 45334, 45349 for the same lesion.

45337 45337 Decompression New language clarifies decompression for pathologic distention, such as volvulus or megacolon.

Includes placement of decompression tube when performed. Report only once per session.

45338 45338 Snare Not separately reportable with endoscopic mucosal resection described by 45349 for the same lesion.

45339 45346 Ablation Code 45339 has been deleted. 

New code 45346 includes balloon dilation, guide wire insertion and ablation. Not separately reportable with dilation code 45340 for the same lesion.

Sigmoidoscopy, flexible

* 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) A 0.96 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple A 1.15

* 45332 Sigmoidoscopy, flexible; with removal of foreign body(s) A 1.79

* 45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps A 1.79

* 45334 Sigmoidoscopy, flexible; with control of bleeding, any method A 2.73 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance A 1.46

* 45337 Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed A 2.36 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique A 2.34 D45339 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique D D 

Sigmoid/Colon Sigmoidoscopy

* diagnostic-45330-APC 146 ? with biopsy(s) or cold forceps removal-45331-APC 146 ? with snare removal-45338- APC 147

* with hot or cautery 45333- APC 147 ? not amenable to hot or snare… – 45339-APC 147 (APC 146 $299.34) (APC 147 $525.41)

CPT Code Procedure Description Facility Payment (National Medicare Avg)¹ APC  Facility Payment  (National Medicare Avg)² Fee When Procedure Is Performed in Hospital or ASC (National Medicare Avg)³ Fee When Procedure Is  Performed in Office
(National Medicare Avg)³ 44388 

Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate
procedure) $420.93
5312
 $752.76
 $170.18
 $359.71 

44389 Colonoscopy through stoma; with biopsy, single or multiple $420.93
5312
 $752.76
 $186.66
 $453.58

45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) $135.76
5311
 $492.45
 $58.40
 $169.82 

45331 Sigmoidoscopy, flexible; with biopsy, single or multiple $275.37
5311
 $492.45
 $75.60
 $260.83 

45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) $420.93
5312
 $752.76
 $200.28
 $386.22

45380 Colonoscopy, flexible; with biopsy, single or multiple $420.93
 5312
 $752.76
 $217.12
 $477.59
  
Flexible Sigmoidoscopy (45331 – 45347)

Colonoscopy (45379 – 45398, 52 Modifier)

Colonoscopy (45379 – 45398, No Modifier) 

CPT book –

Proctosigmoidoscopy- involves examining the rectum and sigmoid colon. 

45300 - 45327

Sigmoidoscopy- involves examining the entire rectum and sigmoid colon and may include examining a portion of the descending colon.

45330 - 45345

Colonoscopy- involves examining the entire colon, from the rectum to the cecum, must include the proximal colon to the splenic flexure, and it may include the terminal ileum. 
45355 - 45392

Colonoscopy vs. Sigmoidoscopy

Lengths of:

• Rigid sigmoidoscope is 25 cm long

• Flexible sigmoidoscope is 50 cm long

• Flexible colonoscope is 200 cm long

Definitions listed in CPT

Sigmoid/Colon

Sigmoidoscopy

* diagnostic-45330-APC 146 ? 

with biopsy(s) or cold forceps  removal-45331-APC 146

* with snare removal-45338- APC 147

* with hot or cautery 45333- APC 147

* not amenable to hot or snare… – 45339-APC 147

(APC 146 $299.34) 

(APC 147 $525.41)

Colorectal Endoscopy

* There are three types of colorectal endoscopy: (1) rigid sigmoidoscopy, (2) flexible sigmoidoscopy and (3) colonoscopy. Rigid sigmoidoscopy permits examination of the lower six to eight inches of the large intestine. In flexible sigmoidoscopy, the lower one-fourth to one-third of the colon is examined. Neither rigid nor flexible sigmoidoscopy requires medication and can be performed in the doctor's office.

* Colonoscopy uses a longer flexible instrument and usually permits inspection of the entire colon. Bowel preparation is
required, and sedation is often used. 

* The colon can also be indirectly examined using the barium enema x-ray technique. This examination uses a barium solution to coat the colon lining. X-rays are taken, and unsuspected polyps are frequently found. 

Case Study - Question

1. Colonoscopy with removal of tumor by snare or bipolar cautery 45384

2. Gastroscopy with biopsy single or multiple 43239

3. Proctosigmoidoscopy with ablation 45339

4. Colonoscopy with removal of tumor by snare technique 45385

Incomplete Colonoscopy

Physician billing: See Medicare Pub 100-4, Chapter 18, Section 60.2

Incomplete or interrupted colonoscopies:

The inability to extend beyond/proximal to the splenic flexure

• Applies to diagnostic and screening

• Medicare value = same as sigmoidoscopy

• When procedure is not completed due to an  adverse event.

• Example: Hypotensive episode

• 45378-53

• G0105-53

CPT states: “For an incomplete colonoscopy with full preparation for a colonoscopy, use a colonoscopy code with modifier 52 and provide documentation” 

Colorectal Cancer Screening – HCPCS Codes

Colorectal cancer screening

• Colonoscopy

• G0105 – high risk pt

• G0121 – non-high risk pt

• Flexible sigmoidoscopy – G0104

• Both have frequency limitations

 “If during a screening colonoscopy, a lesion or growth is removed, biopsied, …, the appropriate “diagnostic” procedure code should be billed and paid rather than code the screening code.

Reporting Examination of the Distal Defunctionalized Colon

CPT provides guidance on how to code for both endoscopic examination of the colon that remains above a stoma (colostomy) and, at the same time, examination of the bypassed or defunctionalized colon. 

If a patient has a colostomy, an exam from stoma to cecum would entail a colonoscopy through stoma (44388 series), and examination of the retained portions of the colon are coded with an anoscopy, proctosigmoidoscopy or flexible sigmoidoscopy code, as appropriate.

QUESTION: What are preventive colorectal cancer (CRC) screening services?

ANSWER: Preventive colorectal cancer screening services include CRC screening tests, such as fecal occult blood test (FOBT), fecal immunochemical test (FIT), flexible sigmoidoscopy, colonoscopy, CT colonography, or CologuardTM .

If a patient undergoes a CRC screening test by another health-care professional and an abnormality (e.g. positive test) is found that prompts referral for a colonoscopy, for Medicare, the colonoscopy is no longer a screening procedure and is no longer a preventive service.

For Medicare, this means that the patient is now responsible for the co-pay and deductible for the diagnostic colonoscopy, as it is not appropriate to code Z12.11 or Z12.12 for the colonoscopy. 

Note that CT colonography is not a covered service for CRC screening for Medicare. Cologuard is a covered service for Medicare beneficiaries.

For commercial payors, check the medical policy to see whether CT colonography and/or Cologuard are covered services for CRC screening. Check the summary plan description (SPD) and/or payor policy to see if a colonoscopy performed in an asymptomatic patient with a positive FOBT, FIT, Cologuard, flexible sigmoidoscopy or CT colonography is or is not still a preventive service (with waiver of financial responsibility).  

Personal or inherited risk of polyposis syndromes:

X Family history of familial adenomatous polyposis (FAP):

• Individual is a genetic carrier:

* Annual flexible sigmoidoscopy or colonoscopy, beginning at age 10 to 15.

• Genetic status is unknown:

* Annual flexible sigmoidoscopy or colonoscopy, beginning at age 10 to 15, until age 24 then:

* Repeat every two years until age 34.

* Repeat every three years until age 44.

* Then every three to five years thereafter.

• Individual is not a carrier:

n Average-risk screening should occur

Lower Endoscopy Definitions

• Proctosigmoidoscopy is the examination of the rectum and may include examination of a portion of the sigmoid colon

• Sigmoidoscopy is the examination of the entire rectum, sigmoid colon and may include examination of a portion of the descending colon

• Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include examination of the terminal ileum or small intestine proximal to an anastomosis

• Colonoscopy through stoma is the examination of the colon, from the colostomy stoma to the cecum or colon-small intestine
anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis

CPT Error:  Report flexible sigmoidoscopy (45330-45347) for endoscopic examination during which the endoscope is not
advanced beyond the splenic flexure  

THIS IS RIGHT BELOW THE INSTRUCTION TO ADD THE 52 AND 53  MODIFIER PARAGRAPHS AND CONTRADICTS THE PREVIOUS INSTRUCTION.  CPT IS GOING TO RELEASE A FIX TO THIS PARAGRAPH INDICATING THAT THE INTENT WOULD BE A FLEXIBLE SIGMOIDOSCOPY

• Report ileoscopy through stoma (44380-44384) for endoscopy examination of a patient who has an ileostomy.

• Report  colonoscopy through stoma (44388-44408) for endoscopic exam of a patient who has undergone segmental resection of the colon (eg, hemicolectomy, sigmoid colectomy, low anterior resection) and has a stoma

• Report proctosigmoidoscopy, sigmoidoscopy or anoscopy, as appropriate for endoscopic exam of a defunctionalized rectum or
distal colon in a patient who has undergone colecotmy, in addition to colonoscopy through stoma or ileoscopy through stoma, if appropriate

• Report flexible sigmoidoscopy (45330-45347) for exam of a patient who has undergone resection of the colon proximal to the sigmoid (subtotal colectomy) and has ileo-sigmoid or ileo-rectal anastomosis)

Colon/Rectum Cancer Work-up

• Sigmoidoscopy

• Colonoscopy

• Biopsy 


Through sigmoidoscopy or colonoscopy, a scope is inserted into the colon to visualize the lining. This may identify tumor size and location. Sigmoidoscopy and colonoscopy are used for screening as well as work-up for cancer of the colon/rectum. Biopsy may be performed at the time of sigmoidoscopy or  colonoscopy to any suspicious lesions. Biopsy will identify the histology, behavior, and grade of the tumor.

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