Monday 9 January 2017

CPT Flexible Sigmoidoscopy

Colonoscopy / Sigmoidoscopy / Proctosigmoidoscopy are generally not covered for:

1. Fulminant colitis

2. Possible perforated viscus

3. Acute severe diverticulitis; or,

4. Diverticulosis- This condition is not usually considered an indication for diagnostic or therapeutic colonoscopy, sigmoidoscopy or proctosigmoidoscopy, but may be reported on the claim when this condition is found to be the final diagnosis.

Marking of a neoplasm for localization (tattooing) is covered, but is not separately payable.

Billing and Coding Guideliens

SIGMOIDOSCOPY within the measurement period or prior four years (Valid dates = 07/01/2009 to 06/30/2014). See Tables 4-6.

** Using claims codes: Provide the service date and code associated  with the sigmoidoscopy procedure.

o Accepted sigmoidoscopy CPT procedure codes: 45330-45335, 45337-45342, 45345.

o Accepted sigmoidoscopy ICD-9 procedure codes: 45.24.

o Accepted sigmoidoscopy HCPCS codes: G0104.

Code G0104 (colorectal cancer screening; flexible sigmoidoscopy) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic flexible sigmoidoscopy (CPT code 45330). (The same RVUs have been assigned to code G0104 as those assigned to CPT code 45330.) 

If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a flexible sigmoidoscopy with biopsy or removal must be billed and paid rather than code G0104.

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.

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

Sigmoidoscopy Service Codes

Code                           Description

45330: Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

45331: Sigmoidoscopy, flexible; with biopsy, single or multiple

45332: Sigmoidoscopy, flexible; with removal of foreign body

45333: Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

45334: Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)

45335: Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance

45337               Sigmoidoscopy, flexible; with decompression of volvulus, any method

45338: Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45339: 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

45340: Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures

SCREENING SIGMOIDOSCOPY, BARIUM ENEMA.

45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination

45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)

45345 Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)

45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes preand  post-dilation and guide wire passage, when performed)

45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection

45350 Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids)

G6022 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesions(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

G6023 Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)

Limitations: 

Endoscopy is generally not covered for treating the following, and records must have additional documentation indicating the medical necessity of the procedure for review as needed:

1. 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

2. Acute diarrhea

3. Hemorrhoids

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

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

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

7. Upper gastrointestinal (GI) bleeding or melena with a demonstrated upper GI source; or,


8. Bright red rectal bleeding with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source

Codes to Identify Flexible Sigmoidoscopy:

CPT: 45330-45335, 45337-45342, 45345, G0104

ICD9 Procedure Codes: 45.24

Colorectal Cancer (CRC) Screening

The Colorectal Cancer Screening quality measure assesses whether adults 50–75 years of age have had appropriate screening for CRC. “Appropriate screening” is defined by meeting any one of these screening methods:

•Fecal occult blood test (FOBT) during the current year.
•Flexible sigmoidoscopy in the current year or the preceding four years.
•Colonoscopy in the current year or the preceding nine years.

WHAT CODES DO I FILE?

When filing claims in the future, you can help improve our awareness of the services you provide related to CDCs by using these codes:

Flexible Sigmoidoscopy

CPT Codes: 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, 45345

HCPCS Codes: G0104

General Information

The Patient Protection and Affordable Care Act (PPACA) provides coverage for preventive screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. 

In addition, in October 2015 the United States Department of Labor issued clarification that related ancillary services are also to be covered at the preventive services benefit level.

A. Colorectal Cancer Screening Services

Moda Health covers the preventive screening for colorectal cancer in accordance with the Patient Protection and Affordable Care Act (PPACA) at 100% (no cost-sharing responsibility to the member), when the member is seeing an in-network provider.

Colorectal cancer screening may be performed using fecal occult blood testing, sigmoidoscopy, colonoscopy, or barium enema alternative colorectal cancer screening.

D. Screening Colonoscopy Or Sigmoidoscopy When No Abnormalities Are Found

If a screening colonoscopy is performed and no abnormalities are found, submit the service with a procedure code specific to a screening colonoscopy (e.g. G0105, G0121).

If a screening sigmoidoscopy is performed and no abnormalities are found, submit the service with a procedure code specific to a screening sigmoidoscopy (e.g. G0104).

E. Screening Colonoscopy Or Sigmoidoscopy Converted To Diagnostic Or Therapeutic Colonoscopy Or Sigmoidoscopy

When an abnormality is encountered during screening colonoscopy or sigmoidoscopy:

* The colonoscopy or sigmoidoscopy is still classified as a preventive service eligible for coverage at the no-member-cost-share benefit level.

* Submit the claim with Z12.11 (Encounter for screening for malignant neoplasm of colon) as the first-listed diagnosis code; this is the reason for the service or encounter. 

Use of Z12.11 in the first diagnosis position is essential to ensure the member’s PPACA no-cost-share benefits are accessed.

* Modifier PT is to be appended to the appropriate diagnostic or therapeutic colonoscopy procedure code(s).

* Claims with diagnostic colonoscopy/sigmoidoscopy procedure codes submitted without modifier PT appended or without Z12.11 as the first-listed diagnosis code will be processed under the member’s normal medical benefit level, not preventive benefits.

* Future colonoscopies or sigmoidoscopies are no longer eligible for Preventive screening benefits under the Patient Protection and Affordable Care Act (PPACA); they are considered diagnostic, monitoring or surveillance testing (see  onitoring or Surveillance Testing below).

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