by Natalie Tornese, CPC
February 1st, 2018
- A Diagnostic colonoscopy is performed when an abnormal finding, sign, or symptom is found such as diarrhea, anemia, abdominal pain, or rectal bleeding
- A Screening colonoscopy is performed on
personwithout symptoms in order to test for the presence of colorectal cancer or colorectal polyps. Even if a polyp or cancer is found during a screening exam, it does not change the screening intent.
- A Surveillance colonoscopy is performed on an asymptomatic patient at an interval less than the standard 10 years from the last colonoscopy (or sooner, in certain high-risk patients), due to findings of cancer or polyps on the previous exam.
- Z12.11: Encounter for screening for malignant neoplasm of the colon
- Z80.0: Family history of malignant neoplasm of digestive organs
- Z86.010: Personal history of colonic polyps
K50 family - Crohn's disease
K51 family - Ulcerative (chronic) proctitis
K52.1 - Toxic gastroenteritis and colitis
K52.89 - Other specified noninfective gastroenteritis and colitis
K52.9 - Noninfective gastroenteritis and colitis, unspecified
Z12.11 - Encounter for screening for malignant neoplasm of colon
Z12.12 - Encounter for screening for malignant neoplasm of rectum
Z15.09 - Genetic susceptibility to other malignant neoplasm
Z80.0 - Family history of malignant neoplasm of digestive organs
Z83.71 - Family history of colonic polyps
Z85.038 - Personal history of other malignant neoplasm of large intestine
Z85.048 - Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Z86.010 Personal history of colonic polyps
Many providers are unsure about a screening and surveillance colonoscopy and how it should be coded for an asymptomatic patient. A www.gastro.org article explains:
- Follow-up colonoscopies are surveillance and not screening if a screening is a service performed in the absence of signs or symptoms, once the patient has a diagnosis of polyps--whether a sessile serrated adenoma (SSA), adenoma or hyperplastic.
- An exam can be reported as a surveillance colonoscopy is the patient has a history of polyps, is now returning for a follow-up exam and is otherwise asymptomatic. Code Z86.010 (Personal history of colonic polyps) should be reported if the previous polyps were benign.
45379 Foreign body(s) removal
45381 Submucosal injection
45382 Control of bleeding
45384 Hot biopsy
45389 Stent placement
45391 Endoscopic ultrasound
45392 Endoscopic ultrasound with FNA
45390 Endoscopic mucosal resection (EMR)
45398 Band ligation
• If the procedure is performed through a stoma rather than the anus, report 44388-44408:
44388 Colonoscopy through stoma
44390 Foreign body(s) removal
44391 Control of bleeding
44392 Hot biopsy
44402 Stent placement
44403 Endoscopic mucosal resection (EMR)
44404 Submucosal injection
44405 Balloon dilation
44406 Endoscopic ultrasound
44407 Endoscopic ultrasound (EUS) with FNA
Closerelative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp. Familyhistory of familial adenomatous polyposis. Familyhistory of hereditary nonpolyposis colorectal cancer.
- Personal history of adenomatous polyps.
- Personal history of colorectal cancer.
- IBD, including Crohn’s disease, and ulcerative colitis.
- PT - The PT modifier indicates that a colonoscopy that was scheduled as a screening was converted to a diagnostic or therapeutic procedure.
- 33 - Modifier 33 modifier should be appended for preventive services when the primary purpose of the service is the delivery of an evidence-based service.
- 53 - Medicare guidelines state that if a patient is scheduled for a screening colonoscopy, but because of poor prep the scope cannot be advanced beyond the splenic fixture, the procedure should be coded as a colonoscopy with modifier 53 (discontinued procedure). The 53 modifier should be added even if the scope was advanced beyond the splenic fixture but the visualization was poor and the physician wants to repeat the procedure within the restricted time period.
- 74 - Modifier 74 (discontinued outpatient procedure after anesthesia administration) should be appended when the colonoscopy is not documented as advanced at least into the transverse colon. The operative report must state why and when the procedure was discontinued. The extent and/or percentage to which the procedure was performed also should be documented.
- 73 - Modifier 73 (discontinued outpatient procedure prior to anesthesia administration) should be appended when the procedure is canceled prior to the insertion of the colonoscopy.
- For gastroenterologists who use anesthesia professionals, the value of the majority of all GI endoscopy procedures has been reduced by 0.10 RVUs.