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00731  Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified ...

Colonoscopy Coding and Reimbursement


What is Screening Colonoscopy?

Screening Colonoscopy is an investigation or testing the patients with a scope who currently has no symptoms but are at high risk for colon / rectal cancer and / or any other abnormality of the Intestinal tract. A screening colonoscopy is used to identify and remove polyps in its precancerous stage before it develops to a cancer. The high risk persons are those with a family / personal history of colon polyps and patients with Inflammatory Bowel disease.

What is the difference between Colonoscopy and Sigmoidoscopy?

In colonoscopy the physician inserts the colonoscope into the anus and advances the scope through the colon past the splenic flexure. The lumen of the colon and rectum is visualized. In Sigmoidoscopy the physician inserts the sigmoidoscope into the anus and advances the scope into the sigmoid colon. The lumen of the sigmoid colon and rectum alone are visualized.

How to report a partial Colonoscopy procedure?

Using Colonoscopy if the sigmoid colon alone is visualized for a diagnostic purpose then the procedure performed would be reported as Sigmoidoscopy i.e to bill CPT 45330 that descries 'Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)' instead of CPT 45378 - Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure). This does not refer to a reduced procedure or a discontinued procedure.

What are the applicable CPT's and ICD's?


CPT's to report Colonoscopy and Sigmoidoscopy

G0104 Colorectal cancer screening; flexible sigmoidoscopy
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
45330-45345 Sigmoidoscopy Services
45378-45392 Colonoscopy Services

ICD-9 Codes that Support Medical Necessity almost for all insurances

V76.41 Screening for malignant neoplasm of the rectum
V76.51 Screening for malignant neoplasm, colon
V67.09 Follow-up examination following other surgery
V10.0 Personal history of malignant neoplasm of unspecified site in gastrointestinal tract
V10.05 Personal history of malignant neoplasm of large intestine
V10.06 Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
V12.72 Personal history of colonic polyps
V16.0 Family history of malignant neoplasm of gastrointestinal tract
211.3 Benign neoplasm of colon
211.4 Benign neoplasm rectum and anal canal
235.2 Neoplasm of uncertain behavior of stomach, intestines, and rectum
569.0 Anal and Rectal Polyp

Preventive benefits are applied to screening colonoscopies or flexible sigmoidoscopies (G-codes when reported with a screening diagnosis V-code); non-preventive benefits are applied for colonoscopies or flexible sigmoidoscopies reported with diagnosis codes for specific illnesses, signs or symptoms. It is important to assign the correct ICD-9-CM diagnosis to the procedures as per the Local Coverage Determinations applicable in CMS
http://www.cms.hhs.gov/mcd/search.asp

How the Colonoscopies are reimbursed?

Each CPT has its Relative Value Units assigned by Centres for Medicare and Medicaid Services (To check the RVU for each CPT please refer
http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp). Accurate coding helps the physician to get the appropriate reimbursement. Consider if the physician performs a cold biopsy [CPT 45380] and a snare polypectomy [CPT 45385] for a patient on the same date of service, the reimbursement would not be fully calculated as per the individual RVUs for both the CPT's whereas the base code for colonoscopy procedure CPT 45378 has to be considered in determining the reimbursement for the Colonoscopies performed on the day. CPT 45378 is a component and a column 2 code for both CPT 45385 and CPT 45380 (To check the list of Column 1 and Column 2 status assigned to Colonoscopy procedures please refer http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=2&sortOrder=ascending&itemID=CMS046401&intNumPerPage=10). The reimbursement ratio is calculated as CPT 45385 + [CPT 45380 - CPT 45378] = Actual reimbursement. This formula applies when multiple endoscopy procedures like Sigmoidoscopy procedures (Base code CPT 45330), Esophagoscopy (Base code CPT 43200) and EGD (Base code CPT 43235) are performed on the same day.

Do Commercial insurance cover Screening Colonoscopy?

Yes, all the commercial carriers would cover routine screening colonoscopy if medically necessary.

Aetna reimbursement for screening colonoscopy: Aetna considers routine screening as medically necessary preventive services for members aged 50 years and older when the tests are recommended by their physician. For more details please refer
http://www.aetna.com/cpb/medical/data/500_599/0516.html

Cigna reimbursement for Screening Colonoscopy:
http://www.cignagovernmentservices.com/partb/pubs/mb/2001/01_3/forall/b0103b06b.html

Humana reimbursement for Screening Colonoscopy:
http://apps.humana.com/tad/tad_new/Search.aspx?criteria=G0121&searchtype=freetext

Tricare Coverage and reimbursement for Colonoscopy
http://www.tricare.mil/survey/hcsurvey/issue-briefs/issuebriefFY06Q2.pdf
http://www.tricare.mil/contracting/healthcare/t3manuals/change2/tp08/C7S2_2.PDF
http://www.medtronsoftware.com/pdf/091709_Tricare%20_Providers-MC_Part_B_Covered_Preventive_Services.pdf


What is Virtual Colonoscopy?

Virtual colonoscopy is also known as Computed Tomographic Colonography (CTC) is a minimally invasive imaging examination of the colon and rectum. CTC uses CT acquired images and advanced 2-dimensional (2D) and 3-dimensional (3D) image display techniques for interpretation. These images are interpreted by a radiologist to determine the presence of several types of abnormalities of the colon. CMS assigned CPT 0066T to report Computed Tomographic Colonography (virtual colonoscopy) screening (investigational) and CPT 0067T to report Computed Tomographic Colonography (virtual colonoscopy) diagnostic.

Important links

CMS Medicare learning Network:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0746.pdf

American Gastroenterology Association:
http://www.gastro.org/user-assets/Documents/03_Practice_Management/Colonoscopy_Bundling_Statement.pdf

Centers for Disease Control and Prevention:
http://www.cdc.gov/cancer/colorectal/

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