Coding Faqs - Screening Colonoscopy Questions

1. How do I bill for a patient seen in our office prior to a screening colonoscopy with no GI symptoms and who is otherwise healthy? 
   
   A visit prior to a screening colonoscopy for a healthy patient is not billable. 
   
   
2. If a patient is referred to our office for a screening colonoscopy and the patient is on Coumadin, can we bill for the visit? 
   
   Yes. If the patient requires some intervention on the part of the gastroenterologist prior to the procedure, you can bill a New Patient or Established Patient visit, depending on whether the patient has received any face-to-face service by any provider of the same specialty in your office within the last three years. 
   
   
3. If a patient is scheduled for a screening colonoscopy and because of a poor prep the scope cannot be advanced beyond the splenic flexure, do I code the procedure as a flexible sigmoidoscopy? 
   
   No. Per Medicare guidelines, the procedure should be codes as a colonoscopy with a 53 modifier which will pay a partial fee and allow you to repeat the procedure within the restricted time period and get full payment for the second procedure. Even if the scope was advanced beyond the splenic flexure, but the visualization was poor and the physician wants to repeat the procedure within the restricted time period, add the 53 modifier. 
   
   
4. If a patient presents for a screening colonoscopy and a polyp is removed during the procedure, what is the correct way to identify the ICD-9 diagnoses codes?
   
   For all payors, if the procedure was initiated as a screening, the screening diagnosis is primary and the polyp is secondary. For example, on form CMS-1500 in the line with the polypectomy procedure code, in Box 24E (the diagnostic pointer box) enter a "2" linking the procedure with the polyp. In this way, the patient will receive the insurance benefits associated with screening procedures and the service will be paid correctly.  
   
5. If a patient is average risk and had a screening colonoscopy two years ago but now presents with symptoms that would justify a diagnostic colonoscopy, will Medicare pay for the second procedure? 
   
   Yes. The time restrictions only apply between two screenings (patient has no symptoms).  
   If a patient presents for a screening colonoscopy and the scope was advanced to the cecum but visualization was poor and the physician wants to repeat the procedure in one year, how do we code the first procedure? 
6. 
   Given Medicare's time restriction of two years between two high risk screenings and 10 years between two average risk procedures, if a screening is repeated in one year, it will be denied by Medicare as "not medically necessary." If the physician wants to repeat the procedure within the restricted time, the first procedure should be billed with a 53 modifier, even though the scope advanced beyond the splenic flexure. 
   What are the new screening benefits for Medicare patients? 
7. 
   Effective January 1, 2011, if a patient presents for a screening colonoscopy or flexible sigmoidoscopy (no GI symptoms), Medicare will waive both the deductible and coinsurance when billing the G codes for the screening. 
   What happens if, during the course of a screening colonoscopy a polyp or lesion is found and the physician performs a biopsy or polypectomy? 
8. 
   If a polyp or lesion is found during the screening procedure, the colonoscopy becomes diagnostic and should be reported with the appropriate diagnostic colonoscopy code (45378-45392). For Medicare patients, the PT modifier would be appended to the code to indicate that this procedure began as a screening test. Medicare will still waive the deductible, but the patient will be responsible for the coinsurance.
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