More than two million colonoscopies are performed each year in the United States, with the majority of them performed on an outpatient basis. Coding colonoscopies has proved to be a challenge to coders-especially those procedures that include biopsy and polyp removal.
Colonoscopies are performed for both diagnostic and therapeutic purposes. Indications for a diagnostic procedure include abnormal rectal examinations, blood in stool, severe pain or discomfort, chronic diarrhea or change in bowel habits, weight loss or anemia. A personal or family history of colon cancer or polyps would also be an indication for a colonoscopy examination. Examples of therapeutic procedures include colonoscopies performed for polyp removal, biopsy, removal of a foreign body or tube, catheter placement or bleeding control.
An endoscopy is a technique for examining the lumen (hollow part) of an organ. The instrument used in a colonoscopy is a flexible, thin tube with a video camera and light at the end called a colonoscope. Other instruments, such as biopsy forceps, can be passed through the colonoscope to perform procedures such as tissue biopsy and polypectomy. The colonoscope is inserted in the anus and the scope is advanced through the colon past the splenic flexure. A colonoscopy includes an examination of the entire colon, from the rectum to the cecum, and may also include examination of the terminal ileum.
The code assignment is determined by the physician's documentation of the procedure performed or the method used to remove the tissue, lesion or polyp. To determine correct code assignment, the code descriptions, their similarities and the intended use of the codes need to be evaluated and understood.
Colonoscopy procedures discussed in this article include CPT codes 45378 through 45385 and HCPCS Level II codes G0105 and G0121:
45378Colonoscopy, flexible, proximal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression.
45380Colonoscopy, flexible, proximal to the splenic flexure; with biopsy, single or multiple.
45381Colonoscopy, flexible, proximal to the splenic flexure; with directed submucosal injection(s), any substance.
45383Colonoscopy, flexible, proximal to the splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.
45384Colonoscopy, flexible, proximal to the splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery.
45385Colonoscopy, flexible, proximal to the splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
G0105Colorectal cancer screening; colonoscopy on individual at high risk.
G0121Colorectal screening; colonoscopy on individual not meeting criteria for high risk.
There are a number of factors that coders need to determine before assigning one of the above colonoscopy codes.
Was another procedure(s) performed during the diagnostic colonoscopy?
If so, what was the procedure(s)?
What was the technique used?
What instruments were used?
Once the above factors are determined, use the following information as guidance to determine when each of the following codes is reported.
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 is used to report diagnostic colonoscopies. All surgical colonoscopy codes include a diagnostic colonoscopy. Therefore, if any other procedure but a brushing or a washing is performed during the diagnostic colonoscopy, code 45378 should not be reported in addition to surgical colonoscopy codes 45380-45385.
Effective Jan. 1, 1998, Medicare created HCPCS Level ll codes G0105 and G0121. These codes are equivalent to and are used in place of CPT code 45378 when reporting outpatient colonoscopies for screening of colorectal cancer on Medicare patients. Code G0105 is used for reporting a screening colonoscopy for patients who are at high risk for colorectal cancer. High risk for colorectal cancer means an individual with one or more of the following:
a close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp.
a family history of familial adenomatous polyposis.
a family history of hereditary nonpolyposis colorectal cancer.
a personal history of adenomatous polyps.
a personal history of colorectal cancer.
inflammatory bowel disease, including Crohn's Disease and ulcerative colitis.
HCPCS Level II code G0121 was created to report colonoscopies performed for colorectal screening on patients not meeting criteria for high risk. If an abnormality is found during a screening colonoscopy that results in a therapeutic procedure (e.g., biopsy, polypectomy, excision of lesion), then the appropriate CPT code is used instead of HCPCS Level II codes G0105 or G0121.
Code 45385, Colonoscopy, flexible, proximal to the splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, is the most often used technique for performing a polypectomy during a colonoscopy. When the snare cautery technique is used, a wire loop is heated and then placed around the desired piece of tissue or polyp to shave off the polyp or lesion. It's important to note that the snare device may be used with or without heat or cautery. The key term in using this code is "snare" removal. Hot snare, cold snare, monopolar snare and bipolar snare should all be reported with code 45385.
Code 45384, Colonoscopy, flexible, proximal to the splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery, is used when bipolar cautery and monopolar cautery forceps are used to remove tissue. Hot biopsy forceps, also called monopolar cautery forceps, create heat in the metal portion of the forceps cup by causing current to flow from the device to a grounding pad on the patient's body to cauterize the lesion or polyp. Bipolar cautery uses current that runs from one portion of the tip of the cautery device to another to cauterize and remove a lesion or polyp.
Unlike the techniques described in codes 45385 and 45384, the terminology used to indicate when code 45383, Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique, should be reported is not as clear cut. The definition of code 45383 can be misleading because it only indicates what techniques the code should not be reported for. The snare technique is reported using code 43585; hot biopsy and bipolar cautery techniques are reported with code 43584. Code 45383 can be reported for the ablation of a tumor, polyp or other lesion including arteriovenous malformations using a number of different devices including heater probe, bipolar cautery probe, or argon laser, argon plasma coagulators (APC).
CPT code 45380, Colonoscopy with biopsy, single or multiple, describes the use of forceps to grasp and remove a small piece of tissue without the application of cautery. The procedure note may describe the biopsy using cold biopsy forceps or may not mention the device at all. The biopsy may be from an obvious lesion that is too large to remove, from a suspicious area of abnormal mucosa, or from a lesion or polyp so small that it can be completely removed during the performance of the biopsy. Colonoscopy with removal by snare technique, 45385, should not be used for the removal of a small polyp by "biopsy" or "cold forceps" technique. All lesions or polyps removed by cold biopsy forceps are reported with code 45380.
Code 45381, Colonoscopy, flexible, proximal to the splenic flexure; with directed submucosal injection(s), any substance, is reported when any substance is injected into the submucosal. Substances include saline, India ink, methylene blue, Botox and steroids. For example, report code 45381 for an injection to "tattoo" an area with India ink for later identification during a subsequent procedure. Code 45381 should be reported as an additional service to any other therapeutic procedure performed at the same time. Code 45381 is not used to report injections to control bleeding.
Code 45382, Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding, (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) is used to describe injection to control bleeding resulting from a number of causes including diverticulosis, angiodysplasia or prior session interventions. Bleeding that starts as a result of an intervention performed during the colonoscopy, such as a polypectomy or biopsy, and is controlled by any method is considered part of the initial therapeutic procedure and should not be reported separately with codes 45382.
When multiple colonoscopy procedures are performed during the same session, documentation must identify the technique used to perform each procedure. One code is used to report multiple procedures performed using the same technique. Multiple codes are reported when more than one procedure was performed using multiple techniques. When more than one colonoscopy code is reported for the same session modifier -59 (Distinct procedural service) may be used.
Guidance on assigning diagnosis codes for screening procedures was provided in the CCS Prep column titled "Become Familiar with Coding Guidelines for Using V Codes." In summary, the accurate assignment of colonoscopy procedure codes depends upon the documentation of the procedure performed and the technique used to perform the procedure. After review of the CPT Assistant references related to colonoscopy and the CCS Prep column related to diagnosis coding for screening procedures, take the following quiz to test your knowledge. Please note that modifier 59 must be appended to the second and subsequent colonoscopy codes for all of the answers with more than one code.
1. A patient is seen in the outpatient clinic for colonoscopy due to family history of colon cancer. The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. The colonoscopy revealed a colonic polyp that was removed by snare technique. How should the diagnoses and CPT procedures for this case be coded?
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
e. V16.0, 211.3, V76.51, G010
2. The physician performs a colonoscopy, performs a submucosal saline injection and then uses bipolar cautery to remove a large colorectal polyp and also uses a bipolar snare to remove a second polyp from the ascending colon. How should the procedures for this case be coded?
b. 45381, 45384; 45385
c. 45384, 45385
d. 45381, 45385
3. The physician performs a colonoscopy and the examination of the descending colon indicates a 3-mm polyp. The polyp is biopsied and then completely removed with the cold biopsy forceps. How should the procedures for this case be coded?
b. 45380, 45385
4. The physician performed a colonoscopy with fulguration of a tumor, removed two polyps by electrocautery snare and cauterized an AVM that was bleeding. How should the procedures for this case be coded?
a. 45385, 45383, 45382
b. 45385, 45385, 45382, 45383
c. 45385, 45383
d. 45385, 45382
1. CPT Assistant, January 2004, pp. 4-8.
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.
Answers to CCS PREP!:
1. c.Assign code V76.51, Special screening for malignant neoplasms, colon, as the first-listed diagnosis because this was a screening colonoscopy. Code V16.0, Family history of malignant neoplasm, gastrointestinal tract, may be assigned as an additional diagnosis. Assign code 211.3, Benign neoplasm of colon as an additional diagnosis. Because the polyp was removed, 45385 is reported to identify the definitive procedure performed.
2.b.Code 45381 is used to report the injection procedure. Because two different polyps were removed using two different techniques, two separate codes should be assigned. In this instance, code 45384 is reported for the bipolar cautery of the polyp and 45385 is reported for the bipolar snare removal. Modifier 59 should be appended to codes 45384 and 45385.
3.a.45380 is the only code reported in this instance. 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.
4.a.Codes 45385, 45383 and 45382 are all reported for this case. Code 45385 is reported once because the same technique was used to remove both polyps. The fulguration of the tumor is reported with code 45383. The control of the bleeding AVM is reported with code 45382. Modifier 59 should be appended to codes 45383 and 45382.