Screening colonoscopies are considered the gold standard of diagnostic tools for the gastroenterologist, and millions are performed in the U.S. each year. The vast majority of these procedures are performed in the outpatient setting, so it's essential coders understand not only diagnostic ICD-9-CM guidelines, but also CPT and HCPCS guidelines for accurate assignment.
Colonoscopies may be performed for either diagnostic or therapeutic reasons, and in some cases a diagnostic colonoscopy may be converted to a therapeutic one, based on the needs of the patient and the actual procedures performed. The coder's task is to understand differing code assignments based on each scenario.
The first step in assigning appropriate codes for a colonoscopy is to determine the reason for the colonoscopy. In many cases the physician will document "screening colonoscopy," or "Colon CA (carcinoma) screening." This means the patient has no presenting symptoms or problems related to their digestive system but has reached the age for routine prophylactic screenings. Diagnosis code V76.51, Special screening for malignant neoplasms, colon, should be assigned as the first-listed diagnosis. It's important to note the V code is assigned as the first-listed diagnosis for a screening procedure, regardless of whether additional findings are documented or treated.
For a screening colonoscopy, if no procedure beyond the diagnostic endoscopy is performed, CPT/HCPCS code assignment depends upon whether or not the patient is a Medicare beneficiary. If the payer is Medicare, one of two HCPCS codes is required:
• G0105: Colorectal cancer screening; colonoscopy on individual at high risk
• G0121: Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
High risk implies one of the following conditions:
• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyposis;
• A family history of hereditary nonpolyposis colorectal cancer;
• A personal history of adenomatous polyps;
• A personal history of colorectal cancer; or
• A personal history of inflammatory bowel disease, including Crohn's disease and ulcerative colitis.
If the patient is not a Medicare beneficiary and no procedure beyond the diagnostic endoscopy is performed, CPT code 45378, Colonoscopy, flexible, proximal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression, should be assigned.
If the physician documents any signs or symptoms related to the GI tract, such as abdominal pain, blood in stool, chronic diarrhea, change in bowel habits, weight loss or blood loss anemia, the V code should not be assigned and a code for the symptom should be assigned as the reason for visit diagnosis. If there are no definitive findings during the colonoscopy, this diagnosis code will also be assigned as the first-listed diagnosis.
Many procedures may be performed through the colonoscope, including polypectomy, biopsy, removal of foreign body or control of bleeding. CPT codes representing these services are found in the range from 45380 through 45385. If more than one of these services is performed during the same operative episode, multiple codes may be assigned, providing that documentation supports differing techniques. When more than one colonoscopy code is assigned for the same operative episode, modifier 59, Distinct procedural service, may be assigned.
If any of these procedures are performed for a Medicare patient on what is initially designated as a screening colonoscopy, the HCPCS G code is not assigned and the appropriate code from the 45380 - 45385 range is reported. All therapeutic colonoscopies include a diagnostic component; code 45378 is not reported separately.
Codes 45383, 45384 and 45385 represent polypectomy procedures and are differentiated based upon the technique employed. Code 45385, which specifies use of a snare technique for polyp removal, is the most commonly performed polypectomy, but code 45384 may also be assigned if the technique documented is via hot biopsy forceps or bipolar cautery. Code 45383 is a bit different in that the technique is not specified, only the fact that the polyp is not amenable to removal via the techniques represented by codes 45384 or 45385. Code 45383 is most commonly reported for polypectomy by heater probe, argon laser or argon plasma coagulators (APC) techniques.
It's important to note that code 45380, representing a colonoscopy with a biopsy, signifies the use of forceps to grasp and remove a small piece of tissue without the use of cautery. The documentation may mention the use of cold biopsy forceps or may not mention the device at all. It is not relevant to code selection whether or not the documentation states that all of a polyp or only a portion of a polyp is removed. If the technique is stated to be by cold biopsy forceps, code 45380 should be assigned and not a code from the 45383 - 45385 code range. Also note that all codes in this range include the terminology "tumor(s), polyp(s), or other lesion(s)," so only one code should be assigned even if multiple lesions or polyps are treated with the same technique.
For additional information on colonoscopy coding, refer to the following articles:
• Coding Clarification: Colonoscopy; CPT Assistant, July 2004, p. 15.
• Questions & Answers: HCPCS Coding Clinic, 3rd Quarter 2004, p. 14.
• Colonoscopy Coding Made Simple; CPT Assistant, January 2004, pp. 4-8.
• Screening Examinations with Definitive Procedure; Coding Clinic, 1st Quarter 2004, p. 11
• Special Issue 2005: CPT Assistant, December 2005, pp. 1-11.
After review of the above listed articles, test your knowledge with the following quiz:
1. A patient with no GI history and no signs or symptoms was seen in an outpatient surgical area for colonoscopy due to a family history of colon cancer. The colonoscopy revealed a colonic polyp that was removed by snare technique. The most appropriate diagnosis and CPT procedures is/are:
a. 211.3, V76.51, V16.0, 45385
b. 211.3, V76.51, V16.0, G0105
c. V76.51, V16.0, 211.3, 45385
d. V76.51, V16.0, 211.3, G0105
2. A colonoscopy was performed, documentation of which included a 4-mm polyp. The polyp was biopsied and then completely removed with the cold biopsy forceps. The final procedure code is:
b. 45380, 45385
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, facility solutions, Ingenix, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com).
CPT is a registered trademark of the American Medical Association.
1. c. Assign V76.51 as the first-listed diagnosis because this was a screening colonoscopy. Code V16.0 is assigned for the family history of GI malignant neoplasm. Also assign code 211.3 for the benign polyp. Because the polyp was removed via snare technique, code 45385 is reported.
2. a. 45380 is the only code reported; if a biopsy is performed on the same lesion that is removed, only the code for the removal is reported. In this instance, the polyp was removed using cold biopsy forceps. According to January 2004 CPT Assistant, removal by cold biopsy forceps is reported with code 45380.