Reporting colonoscopy 2015
A number of revisions were made to reporting colonoscopy in 2015, the lower gastrointestinal (GI) endoscopy codes in the Colon and Rectum subsection of CPT. Definitions were revised or added at the beginning of the subsection and new guidelines were created to further clarify reporting of these procedures:
- 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, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.
- If the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 (discontinued procedure) and provide appropriate documentation,when performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy. Report the appropriate therapeutic colonoscopy code with modifier 52 (reduced services) and provide appropriate documentation, if a therapeutic colonoscopy (44389?44407, 45379, 45380, 45381, 45382, 45384, 45388, 45398) is performed and does not reach the cecum or colon-small intestine anastomosis . Report flexible sigmoidoscopy (45330?45347) for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure.
- Report flexible sigmoidoscopy (45330?45347) for endoscopic examination of a patient who has undergone resection of the colon proximal to the sigmoid (eg, subtotal colectomy) and has an ileo-sigmoid or ileo-rectal anastomosis. Report pouch endoscopy codes (44385, 44386) for endoscopic examination of a patient who has undergone resection of colon with ileo-anal anastomosis (eg, J-pouch).
- Report colonoscopy (45378?45398) for endoscopic examination of a patient who has undergone segmental resection of the colon (eg, hemicolectomy, sigmoid colectomy, low anterior resection).
- For colonoscopy through stoma, see 44388?44408.Report proctosigmoidoscopy (45300?45327), flexible sigmoidoscopy (45330?45347), or anoscopy (46600, 46604, 46606, 46608, 46610, 46611, 46612, 46614, 46615), as appropriate for endoscopic examination of the defunctionalized rectum or distal colon in a patient who has undergone colectomy, in addition to colonoscopy through stoma (44388?44408) or ileoscopy through stoma (44380, 44381, 44382, 44384) if appropriate.
As part of the review of the lower GI endoscopy codes, several stent placement and ablation CPT codes were deleted and new CPT codes were created that added the words ?pre- and post-dilation and guide wire passage, when performed? to the descriptor. In addition, new CPT codes were created for reporting new technology, such as endoscopic hemorrhoid banding.
Category III codes 0226T and 0227T were converted to Category I codes 46601 and 46607. Typically either a colposcope or operating microscope is used for visualization and cannot be separately reported.
Be careful with the use of the diagnosis code; using the wrong one can trigger a denial, even if the diagnosis code is similar to one that will pass
Be specific if your diagnosis is related to abdominal pain. Abdominal pain ?is not automatically payable by some Medicare payers. There has to be documentation indicating that other studies were done prior to determine abnormalities proving that this is not just an isolated episode of abdominal pain, even if it is covered.
Diagnostic colonoscopy should not be confused with a screening colonoscopy. Screening colonoscopy should be reported using a G code. For most payers, a patient is eligible for screening at age 50, with follow-up screenings allowed every 10 years if the original screening is negative.
When billing colonoscopy, pay attention to the discontinued procedure modifier and coterminous complications:
Use modifier 53 (Discontinued procedure) ?if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances,? advises the AGA in its current usage guidelines.
Do not bill a separate service to control bleeding that occurs during a surgical or therapeutic endoscopic procedure, as instructed in the introduction to the endoscopy section in the 2015 CPT Book. This unintended consequence is not considered a separately reportable service but a standard of care and should not be submitted on the claim.
Following are the codes used in Colonoscopy:
- CPT code 45399. This code has been deleted. The new code for unlisted colon procedure is 45399.
? CPT code 45378. Colonoscopy is examination of the entire colon.
? CPT code 45379. “Foreign body(s)” replaces “foreign body.”
? CPT code 45380. Biopsy, not separately reportable with EMR code 45390 for the same lesion.
? CPT code 45381. Submucosal injection, not separately reportable with WMR or control of bleeding codes 45382 and 45390 for the same lesion.
? CPT code 45382. Control of bleeding, “any method” replaces previous examples. Not separately reportable with 45381 or 453938 for same lesion.
? CPT code 45834. Hot biopsy, bipolar cautery was deleted as an example.
? CPT code 45385. Not separately reportable with EMR code 45390 for same lesion.
? CPT code 45386. Dilation, use modifier 59 for each additional stricture dilated. Not separately reportable with 45388 or 45389. If fluoroscopic guidance is used, use 74360.
? CPT code 45388. Ablation, code 45383 has been deleted. New code 45388 includes balloon dilation, guide wire insertion and ablation.
? CPT code 45389. Stent placement, code 45387 has been deleted. New code 45389 includes pre- and post-dilation and guide wire passage. Not separately reportable with 45386. If fluoroscopic guidance is used, use 74360.
? CPT code 45391. Endoscopic ultrasound now specifies exam limited to the rectum, sigmoid, descending, transverse or ascending colon and cecum and adjacent structures. Report only once per session.
? CPT code 45392. Endoscopic ultrasound with Fine Needle Aspiration. Endoscopic ultrasound, now specifies exam limited to the rectum, sigmoid, descending, transverse or ascending colon and cecum and adjacent structures. Report only once per session.
? CPT code 45390. Endoscopic mucosal resection, new code 45390 is not separately reportable with 45380, 45381 or 45393 for the same lesion.
? CPT code 45393. Decompression, new code 45393 for pathologic distention. Report only once per session.
? CPT code 45398. Band ligation, new code 45398 not separately reportable with 45334 for the same lesion. Do not report in conjunction with 45390 or 46221. Report active bleeding with band ligation with 45382.