Saturday 31 January 2015

Medical billing basic - What is CPT

What is CPT? 
CPT was developed by the American Medical Association (AMA) in 1966. The AMA revises and publishes CPT each year to keep pace with changes in medical practice. They delete obsolete procedures, modify existing procedures, and add newly developed procedures. 
Your physicians’ office should make it a policy to order the current book from the AMA each year. Begin using the new CPT codes on January 1. 
•  listing of descriptive terms and five-digit, numeric codes for reporting medical services and procedures performed by physicians. 
• provides a uniform language to accurately designate medical, surgical and diagnostic services. 
•serves as an effective means of reliable nationwide communication between physicians, patients and third-party payers. 


Each time you submit a claim, identify the service provided by using one of these five-digit CPT codes, plus a two-digit modifier when appropriate. 

HCPCS Levels of Codes

HCPCS is the acronym for the Healthcare Common Procedure Coding System. This system is a uniform method for health care providers and medical suppliers to report professional services, procedures, and supplies. 

There are three levels of codes within the HCPCS system: 

Level I. Level I is the largest component, made up of five-digit numeric CPT codes and two-digit modifiers. Both CPT codes and modifiers have descriptive terms for reporting services performed by health care providers. The first edition of CPT was published by the American Medical Association (AMA) in 1966 and it continues to release updates each year. 

Example: 10060 * Incision and drainage of abscess 

Level II. These national codes, created by The Centers for Medicare and Medicaid Services (CMS), were developed to cover services not specifically reported in CPT. Level II HCPCS codes consist of one alpha character (A through V), followed by four numbers. Level II HCPCS modifiers are two-digit codes which can be used with any level of codes. Level II codes are grouped by the type of service or supply they represent and are updated annually by CMS with input from private insurance companies. 
Example: A4580 Cast supplies 

Friday 30 January 2015

E-Prescribing Incentive complete information


Background

The MIPPA authorizes a new incentive program for eligible professionals who are successful electronic prescribers (E-Prescribers) as defined by MIPPA. This new incentive program is in addition to the quality reporting incentive program authorized by Division B of the Tax Relief and Health Care Act of 2006 – Medicare Improvements and Extension Act of 2006 (MIEA-TRHCA) and known as the Physician Quality Reporting Initiative (PQRI). 

The e-prescribing incentive is similar to the PQRI incentive in that reporting periods are one year in length and the incentive is based on the covered professional services furnished by the eligible professional during the reporting year . In addition, MIPPA requires that quality measures that can be reported for purposes of qualifying for the PQRI incentive payment not include e-prescribing measures

Reporting Periods
Reporting periods are for a calendar year, beginning with calendar year 2009 through 2013.

Incentive Amounts

The e-prescribing incentive amount is based on the Secretary’s estimate (based on claims submitted not later than 2 months after the end of the reporting period) of the allowed charges for all such Physician Fee Schedule (PFS) covered professional services furnished by the eligible professional during the reporting period. 


The e-prescribing incentive percent amount for reporting years 2009 - 2010 is 2.0 percent; for reporting years 201
1 - 2012 is 1.0 percent; and for reporting year 2013 it is 0.5 percent.

Incentive Limitations

The incentive does not apply to eligible professionals, for the reporting period, if:

1. The Medicare allowed charges for all covered professional services for the codes to which the e-prescribing
measure applies are less than 10% of the total of the allowed charges under Medicare Part B for all such covered
professional services furnished by the eligible professional.

OR

2. If determined appropriate by the Secretary, the eligible professional does not submit (including both electronically and non-electronically) a sufficient number of prescriptions under Part D

Thursday 29 January 2015

Beneficiaries Eligible for Coverage and Definition of Diabetes



Medicare Part B covers 10 hours of initial training for a beneficiary who has been diagnosed with diabetes.
Diabetes is diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using the following criteria;

• a fasting blood sugar greater than or equal to 126 mg/dL on two different occasions;

• a 2 hour post-glucose challenge greater than or equal to 200 mg/dL on 2 different occasions; or

o a random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes.

Documentation that the beneficiary is diabetic is maintained in the beneficiary’s medical record.

Beneficiaries are eligible to receive follow-up training each calendar year following the year in which they have been certified as requiring initial training or they may receive follow-up training when ordered even if Medicare does not have documentation that initial training has been received. In that instance, contractors shall not deny the follow-up service even though there is no initial training recorded.

Wednesday 28 January 2015

Exceptions to Routine Foot Care Exclusion



1. Necessary and Integral Part of Otherwise Covered Services
In certain circumstances, services ordinarily considered to be routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.

2. Treatment of Warts on Foot
The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.

3. Presence of Systemic Condition
The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a professional that in the absence of such condition(s) would be considered routine (and, therefore, excluded from coverage). Accordingly, foot care that would otherwise be considered routine may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet. (See subsection A.)

In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions.

4. Mycotic Nails

In the absence of a systemic condition, treatment of mycotic nails may be covered.
The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

Tuesday 27 January 2015

Service feature in Child Health Check-Up (formerly EPSDT)

Child Health Check-Up (CHCUP) is available to every Medicaid-eligible child under age (21). It includes screening (or well-child check-ups), diagnosis and treatment.

To provide Child Health Check-Ups, a provider must be enrolled in Medicaid as a provider with a Category of Service (code 55) for Child Health Check-Ups.

As licensed health care professionals you are aware that performing a blood test is a federal  requirement at specific intervals during the “Child Health Check-Up.” This note is to remind you how  important it is to document the blood tests you are performing in compliance with this federal mandate.  Failure to provide documentation can lead to a federal audit and the requirement to repay Medicaid for fees received.  

The CHCUP schedule listed below is based on the American Academy of Pediatrics, ”Recommendations for Preventive Pediatric Health Care” and Florida Medicaid’s recommendation to include the (7) and (9) year old recipients. 

Annual Wellness Visit (AWV) Including Personalized Prevention Plan Services (PPPS) Medicare policy



This expanded coverage, as established at 42 CFR 410.15, is subject to certain eligibility and other limitations that allow payment for an annual wellness visit (AWV), including personalized prevention plan services (PPPS), when performed by qualified health professionals, for an individual who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months. Medicare coinsurance and Part B deductibles do not apply.

The AWV will include the establishment of, or update to, the individual’s medical/family history, measurement of his/her height, weight, body-mass index (BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and disease detection and encouraging patients to obtain the screening and preventive services that may already be covered and paid for under Medicare Part B. Definitions relative to the AWV are included below.

Coverage is available for an AWV that meets the following requirements:

1. It is performed by a health professional; and,
2. It is furnished to an eligible beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and he/she has not received either an IPPE or an AWV providing PPPS within the past 12 months.
Sections 4103 and 4104 of the ACA also provide for a waiver of the Medicare coinsurance and Part B deductible requirements for an AWV effective for services furnished on or after January 1, 2011.

Monday 26 January 2015

ICD 9 - V76.2 - Pap smear



Screening Pap Smears

Effective, January 1, 1998, §4102 of the Balanced Budget Act (BBA) of 1997 (P.L. 105-33) amended §1861(nn) of the Act (42 USC 1395X(nn)) to include coverage every three years for a screening Pap smear or more frequent coverage for women:
1. At high risk for cervical or vaginal cancer; or
2. Of childbearing age who have had a Pap smear during any of the preceding three years indicating the presence of cervical or vaginal cancer or other abnormality.

Effective July 1, 2001, the Consolidated Appropriations Act of 2001 (P.L. 106-554) modifies §1861(nn) to provide Medicare coverage for biennial screening Pap smears. Specifications for frequency limitations are defined below.

For claims with dates of service from January 1, 1998, through June 30, 2001, screening Pap smears are covered when ordered and collected by a doctor of medicine or osteopathy (as defined in §1861(r)(1) of the Act), or other authorized practitioner (e.g., a certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist, who is authorized under State law to perform the examination) under one of the following conditions.

The beneficiary has not had a screening Pap smear test during the preceding three years (i.e., 35 months have passed following the month that the woman had the last covered Pap smear ICD-9-CM code V76.2 is used to indicate special screening for malignant neoplasm, cervix); or

There is evidence (on the basis of her medical history or other findings) that she is of childbearing age and has had an examination that indicated the presence of cervical or vaginal cancer or other abnormalities during any of the preceding three years; and at least 11 months have passed following the month that the last covered Pap smear was performed; or

Sunday 25 January 2015

Cases Involving Referral Laboratory Services - Medicare policy

If the specimen is drawn or received by an independent laboratory approved under the Medicare program that performs a covered test, but the lab refers the specimen to another laboratory in a different carrier jurisdiction for additional tests, the carrier servicing the referring laboratory retains jurisdiction for services performed by the other laboratory. 
Examples of Independent Laboratory Jurisdiction

EXAMPLE 1:  
An independent laboratory located in Oregon performs laboratory services for physicians whose offices are located in several neighboring States.  A physician from Nevada sends specimens to the Oregon laboratory.  If the laboratory sends the results to the physician and accepts assignment, the carrier in Oregon has jurisdiction. 

EXAMPLE 2:  
American Laboratories, Inc., is an independent laboratory company with branch laboratories located in Philadelphia, Pennsylvania, and Wilmington, Delaware, as well as regional laboratories located in Millville, New Jersey, and Boston, Massachusetts. 

The Philadelphia laboratory receives a blood sample from a patient whose physician ordered a complete blood count, an SMAC T-4, and a B12 and folate. The Philadelphia lab performs the complete blood count, but the SMAC T-4 is performed at the Millville lab, while the B12 and folate is performed at the Boston Lab. The Pennsylvania carrier retains jurisdiction for processing the claims if they have certification information and the appropriate fee schedule allowance in house. Otherwise, the local carrier servicing Boston and/or Millville has jurisdiction for processing their claims. 

Screening CPT Codes G0121, G0106, G0120

Screening Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High-Risk for Developing Colorectal Cancer (Code G0121)

Effective for services furnished on or after July 1, 2001, screening colonoscopies (code G0121) are covered when performed under the following conditions:

1. On individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §280.2.3);

2. At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered G0121 screening colonoscopy was performed); and

3. If the individual would otherwise qualify to have covered a G0121 screening colonoscopy based on the above (see §§280.2.2.D.1 and 2) but has had a covered screening flexible sigmoidoscopy (code G0104), then the individual may have a covered G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed.

NOTE: If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0121

Screening Barium Enema Examinations (codes G0106 and G0120)

Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination. The same frequency parameters for screening sigmoidoscopies and screening colonoscopies above apply.

In the case of an individual aged 50 or over, payment may be made for a screening barium enema examination (code G0106) performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed. For example, the beneficiary received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1999. The count starts beginning February 1999. The beneficiary is eligible for another screening barium enema in January 2003.

In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January 2000. The count starts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2002.

The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast barium enema examination.

CPT code G0105, G0121, g0328 - Colorectal cancer screening

CPT Code and Description

G0105 - Colorectal cancer screening; colonoscopy on individual at high risk

G0104 - Colorectal cancer screening; flexible sigmoidoscopy

G0105 - Colorectal cancer screening; colonoscopy on individual at high risk

G0106 - Colorectal cancer screening; alternative to g0104, screening sigmoidoscopy, barium enema

G0120 - Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema.

G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

G0122 - Colorectal cancer screening; barium enema

G0328 - Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous

Colonoscopy Coding - What Happens when a screening becomes diagnostic

Rely on G-Code for Medicare Screenings

Medicare requires that you report colonoscopy screening for eligible patients using either G0105 (Colorectal cancer screening;colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk). These codes define a patient as either “high risk” for colorectal cancer, or “not meeting criteria for high risk.” 

Medicare will allow only select diagnoses to support a high risk classification. These may include: 

• V10.05 — Personal history of malignant neoplasm; gastrointestinal tract; large intestine 

• V10.06 — Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus 

• V12.72 — Personal history of certain other diseases; diseases of digestive system; colonic polyps 

• V16.0 — Family history of malignant neoplasm; gastrointestinal tract 

• V18.5 — Family history of certain other specific conditions; digestive disorders

Other Medicare- approved diagnoses for G0105 include inflammatory bowel disease, Crohn’s disease and ulcerative colitis. 

If the patient meets any of the above criteria, you should list the appropriate risk factor as the primary diagnosis, along with procedure code G0105. 

If the patient does not meet any of the high risk criteria for colorectal cancer, you would report procedure code G0121 with a primary diagnosis of V76.51 (Special screening for malignant neoplasms;colon). 

For example, to report a covered colonoscopy screening for a 62-year-old male with a personal history of malignant neoplasm of the large intestine, you would link the “high risk” procedure code G0105 to a diagnosis of V10.05. 

For an asymptomatic, 50-year-old patient receiving his first Medicare-covered colonoscopy screening, you would instead link a diagnosis of V76.51 to procedure code G0121

HCPCS code G0105

CPT G0105 - Description : Colorectal cancer screening; colonoscopy on individual at high risk

Screening  Colonoscopies For Beneficiaries At High Risk Of Developing Colorectal Cancer (Code G0105) .--Pay for screening  colonoscopies  (code  G0105)  when  performed  by  a  doctor  of medicine  or  osteopathy  at  a  frequency  of  once  every  24  months  for  beneficiaries  at  high  risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed).  The criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.

NOTE:
If during the course of the screening colonoscopy, a lesion or growth is detected which results  in  a biopsy  or  removal  of  the  growth,  the  appropriate  diagnostic  procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105.

There are a variety of methods available for colorectal cancer screening, including fecal occult blood testing, flexible  sigmoidoscopy, colonoscopy, and screening barium enema. It is important that practitioners follow the practice guidelines for screening and follow-up. 

Medicare Guidelines

Cancer screening is a means of detecting disease early, in asymptomatic individuals, with the goal of decreasing morbidity and mortality. Generally, screening examinations, tests, or procedures are not diagnostic of cancer but instead indicate that a cancer may be present. The diagnosis is then made following a workup that generally includes a biopsy and pathologic confirmation. Colorectal cancer screening involves the use of fecal occult blood testing, rigid and flexible sigmoidoscopy, radiographic barium contrast studies, and colonoscopy. 

Effective for services furnished on or after January 1, 1998, Medicare will cover colorectal cancer screening test/procedures for the early detection of colorectal cancer. The following are the coverage criteria for these screening services:

• Annual fecal occult blood tests (FOBTs); 
• Flexible sigmoidoscopy over 4 years;
• Screening colonoscopy for persons at average risk for colorectal cancer every 10 years, 
• Screening colonoscopy for persons at high risk* for colorectal cancer every 2 years; 
• Barium enema every 4 years as an alternative to flexible sigmoidoscopy, or
• Barium enema every 2 years as an alternative to colonoscopy for persons at high risk* for colorectal cancer; 
• Effective for claims with dates of service on or after October 9, 2014, payment may be made for colorectal cancer screening using the Cologuard™ multitarget stool DNA (sDNA) test

* Medicare defines high risk of developing colorectal cancer as someone who has one or more of the following risk factors:

• 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; or
• A personal history of inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis

It is not expected that these screening services are performed on patients that present with active gastrointestinal symptomatology.

Billing for Screening Colonoscopy or Sigmoidoscopy

The AMA created modifier 33 to allow providers to identify a preventive service for which, under The PPACA, there is no patient cost sharing. Use modifier 33 with a CPT code for a diagnostic/treatment service performed as a preventive service, such as a screening colonoscopy, even if a polyp is found and removed.

You may also use G codes intended for use for screening procedures for colorectal cancer  screening:

o G0105: colonoscopy screening for individuals at high risk
o G0121: colonoscopy screening for individuals who are not high risk
o G0104: flexible sigmoidoscopy screening

When billing for preventive screening colonoscopy or sigmoidoscopy for any BCBSMA member, use modifier 33 or one of the G codes above so that the claim pays without any member cost share, according to the member’s benefits.

Do not use modifier 33 to bill for individuals receiving procedures due to signs or symptoms, or to rule out or confirm a suspected diagnosis. In this case, the procedure would be considered a diagnostic exam, not a screening exam. See the table on page 1 for coding examples. As always, be sure to check eligibility and benefits to determine appropriate member cost-sharing

National Guidelines

National guidelines recommend colorectal cancer screening starting at age 50 then every 10 years. However, more frequent or earlier screening is recommended for patients with certain increased risk factors, such as a family history of colon cancer or personal history of polyps. Screening in these situations will now also be covered when billed as a preventive service.

Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). Refer to §60.2 of this chapter for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.

NOTE: If during the course of the screening colonoscopy, a lesion or growth is  detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105. 

G0120 - Colorectal Cancer Screening; Barium Enema; as an Alternative to or

G0105, Screening Colonoscopy

Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (code G0105) examination. The same frequency parameters for screening colonoscopies (see those codes above) apply. 

In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January 2000. Start counts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2002. 

Denial reason

If the claim is being denied because payment has already been made for a screening fecal-occult blood test (G0107 or G0328), flexible sigmoidoscopy (code G0104), screening colonoscopy (code G0105), or a screening barium enema (codes G0106 or G0120), MSN message 18.16 is used:

This service is denied because payment has already been made for a similar procedure within a set timeframe.

NOTE: MSN message 18-16 should only be used when a certain screening procedure is performed as an alternative to another screening procedure. For example: If the claims history indicates a payment has been made for code G0120 and an incoming claim is  submitted for code G0105 within 24 months, the incoming claim should be denied. 

Deductible and Coinsurance

There is no deductible and no coinsurance or copayment for the FOBTs (HCPCS G0107, G0328), flexible sigmoidoscopies (G0104), colonoscopies on individuals at high risk (HCPCS G0105), or colonoscopies on individuals not meeting criteria of high risk (HCPCS G0121). 

When a screening colonoscopy becomes a diagnostic colonoscopy anesthesia code 00810 should be submitted with only the -PT modifier and only the deductible will be waived

Prior to January 1, 2007 deductible and coinsurance apply to other colorectal procedures (HCPCS G0106 and G0120). After January 1, 2007, the deductible is waived for those tests. Coinsurance applies.

Effective January 1, 2015, coinsurance and deductible are waived for anesthesia services CPT 00810, Anesthesia for lower intestinal endoscopic procedures, endoscope introduceddistal to duodenum, when performed for screening colonoscopy services and when billed  with Modifier 33.

COLORECTAL CANCER SCREENING

Covered Services and HCPCS Codes.-- Medicare covers colorectal cancer screening test/procedures for the early detection of colorectal cancer for the HCPCS codes indicated.

A. Effective for Services Furnished on or After January 1, 1998.-- G0107--Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations;

G0104--Colorectal cancer screening; flexible sigmoidoscopy;

G0105--Colorectal cancer screening; colonoscopy on individual at high risk;

G0106--Colorectal cancer screening; barium enema; as an alternative to G0104, screening sigmoidoscopy;

G0120--Colorectal cancer screening; barium enema; as an alternative to G0105, screening colonoscopy.

Coverage Criteria.--The following are the coverage criteria for these screenings:

A. Screening Fecal-Occult Blood Tests (Code G0107).--Effective for services furnished on or after January 1, 1998, pay for screening fecal-occult blood tests (code G0107) for beneficiaries who have attained age 50, and at a frequency of once every 12 months (i.e., at least 11 months have passed following the month in which the last covered screening fecal-occult blood test was done). Screening fecal-occult blood test means a guaiac-based test for peroxidase activity, in which the beneficiary completes it by taking samples from two different sites of three consecutive stools. 

This screening requires a written order from the beneficiary’s attending physician. (The term “attending physician” is defined to mean a doctor of medicine or osteopathy (as defined in §1861(r) (1) of the Social Security Act) who is fully knowledgeable about the beneficiary’s medical condition, and who would be responsible for using the results of any examination performed in the overall management of the beneficiary’s specific medical problem.)

B. Screening Flexible Sigmoidoscopies (code G0104).—For claims with dates of service on or after January 1, 2002, pay for screening flexible sigmoidoscopies (Code G0104) for beneficiaries who have attained age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist at the frequencies noted below. For claims with dates of service prior to January 1, 2002, pay for these services under the conditions noted only when they are performed by a doctor of medicine or osteopathy.

For services furnished from January 1, 1998, through June 30, 2001, inclusive:

Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was done). For services furnished on or after July 1, 2001:

Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §4180.3) and he/she has had a screening colonoscopy (code G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (code G0121).

NOTE: If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal should be billed and paid rather than code G0104.

C. Screening Colonoscopies For Beneficiaries At High Risk Of Developing Colorectal Cancer (Code G0105).--Pay for screening colonoscopies (code G0105) when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). Refer to §4180.3 for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.

NOTE: If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105.

D. Screening Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High-Risk for Developing Colorectal Cancer (Code G0121).--Effective for services furnished on or after July 1, 2001, pay for screening colonoscopies (code G0121) performed under the following conditions:

1. On individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §4180.3).

2. At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered G0121 screening colonoscopy was performed).

3. If the individual would otherwise qualify to have covered a G0121 screening colonoscopy based on the above (see §4180.2.D.1 and .2) but has had a covered screening flexible sigmoidoscopy (code G0104), then he or she may have covered a G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed.

NOTE: If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G012

E. Screening Barium Enema Examinations (codes G0106 and G0120).--Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination. The same frequency parameters for screening sigmoidoscopies and screening colonoscopies (see §4180.2 B and C) above apply.

In the case of an individual aged 50 or over, payment may be made for a screening barium enema examination (code G0106) performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed. For example, the beneficiary received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema in January 2002.

In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2000.

The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast barium enema examination

Noncovered Services.--The following noncovered HCPCS codes are used to allow claims to be billed and denied for beneficiaries who need a Medicare denial for other insurance purposes for the dates of service indicated:

A. From January 1, 1998 Through June 30, 2001, Inclusive.--Code G0121 (colorectal cancer screening; colonoscopy on an individual not meeting criteria for high risk) should be used when this procedure is performed on a beneficiary who does NOT meet the criteria for high risk. This service should be denied as noncovered because it fails to meet the requirements of the benefit for these dates of service. The beneficiary is liable for payment. Note that this code is a covered service for dates of service on or after July 1, 2001.

B. On or After January 1, 1998.--Code G0122 (colorectal cancer screening; barium enema) should be used when a screening barium enema is performed NOT as an alternative to either a screening colonoscopy (code G0105) or a screening flexible sigmoidoscopy (code G0104). This service should be denied as noncovered because it fails to meet the requirements of the benefit. The beneficiary is liable for payment.

Payment Requirements.--Code G0107 (colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations) must be paid at the rates established for this code under the clinical laboratory fee schedule.

Code G0104 (colorectal cancer screening; flexible sigmoidoscopy) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic flexible sigmoidoscopy (CPT code 45330). (The same RVUs have been assigned to code G0104 as those assigned to CPT code 45330.) If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a flexible sigmoidoscopy with biopsy or removal must be billed and paid rather than code G0104.

Codes G0105 and G0121 (colorectal cancer screening colonoscopies) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic colonoscopy (CPT code 45378). (The same RVUs have been assigned to codes G0105 and G0121 as those assigned to CPT code 45378.) If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a colonoscopy with biopsy or removal must be billed and paid rather than code G0105 or G0121.

Code G0106 (colorectal cancer screening; barium enema as an alternative to a screening flexible sigmoidoscopy) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280).

Code G0120 (colorectal cancer screening; barium enema as an alternative to a screening colonoscopy; high risk individuals) must be paid at rates consistent with payment for similar or related services  under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280).

Colonoscopy coding - CPT 45378,G0105,G0121

How to Code Colonoscopy 

Colonoscopy is the examination of the entire colon from the rectum to cecum. A colonoscope is inserted in the anus and moved through the colon past the splenic flexure in order to visualize the lumen of rectum and colon.

Always a surgical endoscopy includes a diagnotic endoscopy.

For an incomplete colonoscopy, with full preparation for a colonoscopy, use a colonoscopy code with the modifier 52 and provide information.

A diagnostic colonoscopy is a screening of the colon for any abnormalities without performing any procedure.

A colonoscopy with biopsy, polypectomy, or any removal of foreign body or any other intervention is not considered as diagnostic colonoscopy.

Colonoscopy Codes:

45378 Diagnostic/screening colonoscopy for non-medicare patients. Fee amount $381.1
G0105 Screening Colonoscopy for medicare high risk patients
G0121 Screening colonoscpy for other medicare patients.

Colonoscopy with other procedures.

45379 Colonoscopy with removal of foreign body.
45380 Colonoscopy with biopsy single/multiple.
45381 Colonoscopy with directed submucosal injection.
45382 Colonoscopy with control of bleeding.

Polyps or lesions are removed by hot biospy, cold biopsy, and snare techniques. Depending on the technique the codes are differentiated.

45383 Colonoscopy with ablation of tumors, polyps, or other lesions not amenable to removal by hot biopsy forceps.
45384 removal of polps or other lesions by hot biopsy
45385 removal of polyps or lesions by snare technique.

Colonoscopy

The definition of a colonoscopy examination is now specifically described in CPT as the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.

 When performing a diagnostic or screening procedure on a patient who is scheduled and prepared for a total colonoscopy, 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 and provide appropriate documentation.

 If a therapeutic examination colonoscopy is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

Screening colonoscopy for a low risk patient with no findings during the colonoscopy.  The colonoscopy procedure code: o 45378 with modifier 33 indicating that the
service was preventive OR o G0121 The screening diagnosis code: o V76.51

Guidelines 

New definition. Colonoscopy is the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis. For screening or diagnostic colonoscopy, report 45378 with modifier 53 if unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances and provide appropriate documentation. For therapeutic examinations that do not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

Modifier 51 Examples

• Colonoscopy (45378) performed at the same session as upper endoscopy (43200). Use modifier 51 on the upper endoscopy (43200) because the RVU’s are lower than the colonoscopy (45378). 45378, 43200-51.

Correct Use of Modifier PT 

Screening Colonoscopy or Flexible Sigmoidoscopy converted to diagnostic test or therapeutic procedure.

CPT Codes:  45378-45392,
45331-45345,
G0104-G0106,
G0120-G0121, 74270

No copay applies when Modifier PT is added to the diagnostic test or therapeutic procedure code.

Deductible is waived for surgical services related to the colonoscopy / sigmoidoscopy on the same day as the screening test.

Modifiers 33 and PT are key components to submitting accurate preventive services claims; as such, it’s important to review and become familiar with the following billing guidance.

This modifier may be used to identify when a service was initiated as a preventive service, which then resulted in a conversion to a therapeutic service. The most notable example of this is screening colonoscopy (code 45378), which results in a polypectomy (code 45383).

BCBS Guideline

The BCBSMA Policy is predicated on the reason the colonoscopy visit was scheduled. If the visit was scheduled as routine and a finding was discovered during the procedure, the visit is considered routine. Please see the sample billing guidelines below:

If the service is a:    Screening colonoscopy for a low risk patient with no findings during the colonoscopy

The colonoscopy procedure code:

o 45378 with modifier  33 indicating that the service was preventive OR o G0121

The screening diagnosis code:

o V76.51

If the service is a:  Diagnostic colonoscopy performed due to signs or symptoms, or to ruleout or confirm a suspected diagnosis

Procedure                  Diagnosis

The colonoscopy procedure code:

o 45378 WITHOUT  modifier 33

o DO NOT use the G screening codes listed above

Medicare Guidelines

Effective for services performed on or after January 1, 2016, the Medicare Physician Fee Schedule (MPFS) database will have specific values for Current Procedural Terminology (CPT) codes 44388-53; 45378-53; G0105-53; and G0121-53

Background

According to CPT instruction, prior to calendar year (CY) 2015, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Physicians were previously instructed to report an incomplete colonoscopy with 45378 and append Modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy.

In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states:

“When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, 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 and provide appropriate documentation.”

Therefore, in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) has applied specified values in the Medicare Physician Fee Schedule (MPFS) database for the following codes:

** 44388-53 (colonoscopy through stoma);

** 45378-53 (colonoscopy);

** G0105-53 (colorectal cancer screening; colonoscopy on individual at high risk; and

** G0121-53 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Digestive System

Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)

An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

QUESTION: Is there a difference regarding the use of modifiers 52 and 53 with regards to upper and lower endoscopic procedures?

ANSWER: Yes.

EGD procedures: To report esophagogastroscopy where the duodenum is deliberately not examined (e.g., judged clinically not pertinent) or because significant situations preclude such exam (e.g., significant gastric retention precludes safe exam of duodenum), append modifier 52, if repeat examination is not planned, or modifier 53, if repeat examination is planned.

• Example: EGD is performed and a tube is placed into the stomach. The duodenum is not examined and there is no plan to perform repeat EGD to examine the duodenum. Report procedure with modifier 52.

• Example: EGD is performed for evaluation of GI bleeding; the stomach is full of blood and the duodenum is not examined. Plan to control bleeding, lavage stomach and repeat upper endoscopy. Report procedure with modifier 53.

Colonoscopy procedures:

• When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, 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 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 the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

QUESTION: What are the CPT and ICD-10 codes for screening and surveillance colonoscopy?

ANSWER: Check with the payor as to which codes to bill the colonoscopy and the acceptable ICD-10 codes.

Payors other than Medicare may allow additional ICD-10 codes for meeting criteria for screening and surveillance colonoscopy.

Billing for a screening colonoscopy in an average-risk patient:

• G0121 (Medicare) or 45378 (Medicaid, commercial, exchange, Tricare) with the appropriate ICD-10 code for screening:

Z12.11 — encounter for screening for malignant neoplasm of colon.

Z12.12 — encounter for screening for malignant neoplasm of rectum.

Billing for screening colonoscopy in a high-risk patient:

• G0105 (Medicare) or 45378 (Medicaid, commercial, exchange, Tricare) with the appropriate ICD-10 code for screening:

 K50 — Crohn’s disease.

 K51 — ulcerative colitis.

 K52.1 — toxic gastroenteritis and colitis.

 K52.89 — other specified noninfective gastroenteritis and colitis.

 K52.9 — noninfective gastroenteritis and colitis, unspecified.

 Z85.038 — personal history of other malignant lesion of large intestine.

 Z85.048 — personal history of other malignant lesion of rectum, rectosigmoid junction and anus.

 D12.6 — benign neoplasm of colon, unspecified.

Z15.09 — genetic susceptibility of other malignant neoplasm.

 Z80.0 — family history of malignant neoplasm of digestive organs.

 Z83.71 — family history of colonic polyps.

 Z86.010 — personal history of benign neoplasm of colon.

•When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, 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.

EMR Colon 2015 Medicare

• G6021 Unlisted service, colon – By itself or as secondary code to snare removal code

• Flex sig: 45338 + 45399

• Colon through stoma: 44394 + 45399

• Colonoscopy: 45385 + 45399

• Cover letter “colonoscopy counterpart to 43254 EGD with EMR” can suggest same $ increment (43254-43235) be added to 45378

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