Colonoscopy Billing Tips – CPT 45380, 45385
As a speaker at many national conferences, I find the question most frequently asked is, “What is the proper way to code a screening colonoscopy?” First, let’s talk about what is a screening colonoscopy. Physicians suggest a colorectal cancer screening (colonoscopy) typically when a healthy patient turns age 50. The procedure entails a colonoscope inserted in the anus moved through the colon past the splenic flexure in order to visualize the lumen of the rectum and the colon. It is used to provide an early diagnosis of colorectal cancer, diverticulosis, ulcerative colitis, Crohn’s disease, etc. The diagnosis code for the screening is selected from the V code section V76.51 (Special screening for malignant neoplasms, colon). The CPT code would be 45378 (Colonoscopy, flexible, proximal to splenic flexure, diagnostic).
Polypectomies
If during the screening a polyp is discovered and a polypectomy is performed, the ICD-9 coding sequence would be V76.51 as your primary diagnosis, and the polyp or abnormality as secondary. When choosing the procedure code, look at the technique used to remove the polyps. (Note: This is not all-inclusive list; please see the current edition of CPT for a complete list of polypectomy codes). Here are some examples:
- 45380—Colonoscopy, with biopsy, single or multiple. Hint: The physician may use the words “biopsy forceps,” or “Jumbo forceps.” Fee amount $468.96
- 45385—Colonoscopy, with removal of tumor(s), polyp(s), lesion(s) by snare technique. Hint: This code covers both cold and hot snare. $494.53
Regardless of how many polyps are removed, you may only use each of these codes once.
Medicare Screenings
Medicare has slightly different code selections for colorectal screenings. Let’s talk about the ICD-9 code selections. For a Medicare patient, you would report V76.51 as the primary diagnosis. Then you must check if the patient is considered a high risk. There are specific criteria that CMS requires for a patient to be categorized as “high risk.” To establish the patient as “high risk,” the patient should exhibit one or more of the conditions found on the CMS list, which you should report as a secondary diagnosis to V76.51. Here are some examples:
- V10.05—Personal history of malignant neoplasm, large intestine
- V12.72—Personal history of colonic polyps
- 556.0—Ulcerative (chronic) enterocolitis
NOTE: This is not all-inclusive. Please review the complete list at http://www.cms.hhs.gov/ as well as local carriers, as they may have specific requirements. As a facility coder, it is advised that you check the patient’s chart, specifically the history and physical as well as the operative report, to ensure proper documentation supports the criteria. If the patient does not meet any of the criteria, then the patient is considered at average risk for colorectal cancer.
The risk factor will determine the procedure code. You should choose one of the following: orectal cancer screening; colonoscopy for an individual not meeting criterion for high risk (average risk):
- G0105—Colorectal cancer screening; colonoscopy for an individual at high risk.
Incomplete Colonoscopies
For coding purposes, the colonoscope must pass the splenic flexure. If this is not achieved, it is an incomplete colonoscopy. In these instances, you should use the CPT code for the procedure intended and append one of the following modifiers:
- Modifier 73—Discontinued procedure due to extenuating circumstances or those threatening the well being of the patient prior to the administration of anesthesia. The physician may cancel or discontinue the procedure subsequent to the patient’s surgical preparation (including sedation, and being taken to the room where the procedure is to be performed).
- Modifier 74—Discontinued procedure due to extenuating circumstances or those threatening the well being of the patient after the administration of anesthesia, or after the procedure was started.
When using these modifiers, it is important to have supporting documentation that clearly states how far the scope was inserted and the reason for the discontinuation. This information should be sent with the claim form for proper reimbursement.
Billing and Coding Guidelines
Medicare pay the full value of the highest valued endoscopy (if the same base is shared), plus the difference between the next highest and the base endoscopy.
Example: In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 for the highest valued procedure (45385) and 50 for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).
Medicare contractors:
• Assume the following fee schedule amounts for these codes: 45378 – $255.40; 45380 – $285.98; 45385 – $374.56; and
• Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.
NOTE: If an endoscopic procedure with an indicator of ‘3’ (Special rules for multiple endoscopic procedures) is billed with other procedures that are not endoscopies (procedures with an indicator of ‘2’ (Standard payment adjustment rules for multiple procedures)), the standard multiple surgery rules apply.
Multiple Endoscopy Example (Same Family)
Determine the highest valued endoscopic procedure (not subject to the multiple endoscopy rule) For the other endoscopic procedures in the same family, apply the standard multiple procedure reduction
EXAMPLE
In the course of performing a fiber optic colonoscopy (Current Procedural Terminology (CPT®)1 code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. When multiple procedures are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). In this example, 45385 is reported without a modifier 51 and is not subject to an adjustment, Code 45380 is subject to adjustment. Append modifier 59 to 45380 to indicate that the polyp removal and lesion removal were at separate site and both should be considered.
45385
45380 – 51 – 59 Subject to adjustment
NOTE: If an endoscopic procedure with an indicator of “3” is billed with the “-51” modifier with other procedures that are not endoscopies (procedures with an indicator of “1”), the standard multiple procedure reduction rules apply.
Anthem Central Region bundles 45380 as incidental with 45385. Based on the Correct Coding Edits for Comprehensive Codes 40000-49999, code 45380 is listed as a component code to 45385. Based on CPT Assistant article:
“From a CPT coding perspective, if the same lesion is biopsied, and subsequently removed during the same operative session, then you should only report the code for the removal of the lesion.” Therefore, if 45380 is submitted with 45385–only 45385 reimburses.
QUESTION: Could you provide some examples of how to use and report modifiers 52 and 53 with regards to lower endoscopic procedures?
ANSWER: Yes.
Example: 54-year-old undergoing screening colonoscopy. Obstructing mass found in the transverse colon, which prevented examination of the right colon. Biopsies were taken. Modifier 52 and either modifier PT (if a Medicare beneficiary) or 33 (if a commercial, Medicaid, Tricare patient) would be added to 45380. This indicates the procedure was intended to be screening; but once a biopsy was performed it became therapeutic, and as it was incomplete, modifier 52 is reported.
Endoscopies
If multiple endoscopies are billed, special rules for multiple endoscopic procedures apply. Medicare contractors will perform the following actions when multiple HCPCS/CPT codes with a payment policy indicator of ‘3’ (Special rules for multiple endoscopic procedures), with the same date of service, are present:
1. Identify if the billed codes share the same Endoscopic Base Code (using the Physician Fee Schedule Payment Policy Indicator File).
2. Pay the full value of the highest valued endoscopy (if the same base is shared), plus the difference between the next highest and the base endoscopy.
Example: In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 for the highest valued procedure (45385) and 50 for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).
Medicare contractors:
• Assume the following fee schedule amounts for these codes: 45378 – $255.40; 45380 – $285.98; 45385 – $374.56; and
• Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.
NOTE: If an endoscopic procedure with an indicator of ‘3’ (Special rules for multiple endoscopic procedures) is billed with other procedures that are not endoscopies (procedures with an indicator of ‘2’ (Standard payment adjustment rules for multiple procedures)), the standard multiple surgery rules apply.
•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 the appropriate therapeutic colonoscopy code with modifier 52 (reduced services) and provide appropriate documentation.
Medicare contractors shall perform the following actions when multiple CPT/HCPCS codes with a payment policy indicator of ‘3’ (Special Rules for Multiple Endoscopies), with the same date of service, are present:
1. Identify if the billed codes share the same Endoscopic Base Code (using the Physician Fee Schedule Payment Policy Indicator File).
2. If the same base is shared, pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy.
EXAMPLE: In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in. Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).
Assume the following fee schedule amounts for these codes:
45378 – $255.40
45380 – $285.98
45385 – $374.56
Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.
NOTE: If an endoscopic procedure with an indicator of ‘3’ is billed with other procedures that are not endoscopies (procedures with an indicator of ‘2’), the standard multiple surgery rules apply. See BRs 7587.1-7587.5 for required actions.
How will my coverage reimburse for each of the following CPT codes and associated diagnoses?
1. CPT Code: 45380 Diagnosis: Clinical Findings such as polyp (211.3)
Rationale Edit
Anthem Central Region bundles 45380 as incidental with 45385. Based on the Correct Coding Edits for Comprehensive Codes 40000-49999, code 45380 is listed as a component code to 45385.
Based on CPT Assistant article:
“From a CPT coding perspective, if the same lesion is biopsied, and subsequently removed during the same operative session, then you should only report the code for the removal of the lesion.”
Therefore, if 45380 is submitted with 45385–only 45385 reimburses.
Anthem Central Region does not bundle 45380-59 with 45385. Based on CPT Assistant article :
“However, if one lesion is biopsied and separate lesion is removed during the same operative session, then it would be appropriate to report a code for the biopsy of one lesion, and an additional code for the removal of the separate lesion. Under certain circumstances the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same date. Modifier -59, Distinct Procedural Service, is used to identify Procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, eparate incision/excision, separate lesion, or separate injury {or area of injury in extensive injuries} not ordinarily encountered or performed on the same day by the same physician. Therefore, if one lesion is biopsied and a separate lesion is removed, then it would be appropriate to append modifier -59 to the code reported for the biopsy.”
Therefore, if 45380-59 is submitted with 45385–both reimburse separately. If on appeal, it is documented that one lesion was biopsied and another lesion was removed then both may reimburse separately.
