Monday 9 January 2017

CPT Code for Colonoscopy and Sigmoidoscopy

CPT codes - Sigmoidoscopy Colonoscopy Service Codes
Colon Cancer Screening - Provider Billing Guidelines and Documentation

Fecal Occult Blood Test Service Codes

Code            Description

82270     Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection)

82272    Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening

G0328     COLORECTAL CANCER SCREENING; FECAL OCCULT BLOOD TEST, IMMUNOASSAY, 1-3 SIMULTANEOUS DETERMINATIONS

Barium Enema Service Codes

Code                   Description

74270       Radiologic examination, colon; contrast (eg, barium) enema, with or without KUB

74280       Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon

G0122       COLORECTAL CANCER SCREENING; BARIUM ENEMA

Sigmoidoscopy Service Codes

Code                           Description

45330              Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

45331              Sigmoidoscopy, flexible; with biopsy, single or multiple

45332              Sigmoidoscopy, flexible; with removal of foreign body

45333              Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

45334              Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)

45335               Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance

45337               Sigmoidoscopy, flexible; with decompression of volvulus, any method

45338               Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45339               Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

45340               Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures

G0104              COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY

G0106              COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA.

Colonoscopy Service Codes

Code                       Description

44388                     Colonoscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

44389                     Colonoscopy through stoma; with biopsy, single or multiple
44390                     Colonoscopy through stoma; with removal of foreign body

44391                     Colonoscopy through stoma; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)

44392                     Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps and bipolar cautery

44393                     Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

44394                     Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45355                    Colonoscopy, rigid or flexible, transabdominal via colostomy, single or multiple

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)

45379                    Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body

45380                    Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple

45381                    Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance

45382                    Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)

45383                    Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.

45384                  Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

45385                  Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45387                  Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation)

G0105                  Colorectal Cancer Screening; Colonoscopy on individual at high risk

G0120                  Colorectal Cancer Screening; alternative to G0105, screening colonoscopy, barium enema

G0121                  Colorectal Cancer Screening; Colonoscopy on individual not meeting criteria for high risk.

Flexible Sigmoidoscopy cpt code 45330, 45331, 45332, 45334
Flexible Sigmoidoscopy

Specific instructions for reporting flexible sigmoidoscopy have been added to the section guidelines. Report flexible sigmoidoscopy for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure. 

Report flexible sigmoidoscopy for endoscopic examination of a patient who has undergone resection of the colon proximal to the sigmoid (e.g., subtotal colectomy) and has an ileo-sigmoid or ileo-rectal anastomosis. 

New codes for the flexible sigmoidoscopy family include endoscopic mucosal resection and band ligation. Revised codes address appropriate reporting of ablation and stent placement.

CPT Code Short Description Summary of Changes

45330  Flexible sigmoidoscopy Editorial: “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).”

45331  Biopsy Not separately reportable with EMR code 45349 for the same lesion.

45332  Foreign body(s) removal “Foreign body(s)” replaces “foreign body.”

45333  Hot Biopsy Bipolar cautery was deleted as an example.

45334  Control of bleeding “Any method” replaces previous examples. Not separately reportable with injection or banding of hemorrhoids described by 45335, 45350 for same lesion.

45335  Submucosal injection Not separately reportable with control of bleeding or endoscopic mucosal resection described by 45334, 45349 for the same lesion.

45337  Decompression New language clarifies decompression for pathologic distention, such as volvulus or megacolon. Includes placement of decompression tube when performed. Report only once per session.

45338  Snare Not separately reportable with endoscopic mucosal resection described by 45349 for the same lesion.

45346  Ablation Code 45339 has been deleted. New code 45346 includes balloon dilation, guide wire insertion and ablation. Not
separately reportable with dilation code 45340 for the same lesion.

45340  Dilation New language specifies use of transendoscopic balloon. Dilation of multiple strictures can be reported with the 59 modifier for each additional stricture dilated. Not separately reportable with ablation or stent placement described by 45346, 45347. Use 74360 if fluoroscopic guidance is performed.

45341  Endoscopic ultrasound Not separately reportable with EUS FNA code 45342 or radiologic ultrasound codes 76872, 76975. Report only once per session.

45342  Endoscopic ultrasound (EUS) with FNA Not separately reportable with EUS code 45341 or radiologic ultrasound codes 76872, 76942, 76975. Report only once per session.

45347  Stent placement Code 45345 has been deleted. New code 45347 includes pre- and post-dilation and guide wire passage. Not separately reportable with dilation code 45340. Use 74360 if fluoroscopic guidance is performed.

45349   Endoscopic mucosal resection (EMR) New code 45349 is not separately reportable with biopsy, submucosal injection, snare or band ligation described by 45331, 45335, 45338, 45350 for the same lesion.

45350  Band ligation New code 45350 is not separately reportable with control of bleeding code 45334 for the same lesion. Do not report in conjunction with EMR or hemorrhoidectomy described by 45349, 46221. Report control of active bleeding with 45334. Report only once per session.


Sigmoidoscopy 

A flexible sigmoidoscopy (SIG-moy-DAH-skuh-pee) exam is a short colonoscopy exam, limited to the lower one third of the colon. Sigmoidoscopy enables the physician to look at the sigmoid colon. Physicians may use this procedure to find the cause of diarrhea, abdominal pain, or constipation. 

They also use sigmoidoscopy to look for early signs of cancer in the colon and rectum. With sigmoidoscopy, the physician can see bleeding, inflammation, abnormal growths, and ulcers. 

Sigmoidoscopy takes 10 to 20 minutes. During the procedure, you might feel pressure and slight cramping in your lower abdomen. You will feel better afterwards when the air leaves your colon. 

The discovery of a polyp on flexible sigmoidoscopy necessitates a complete colon inspection with a colonoscope, since at least 30 percent of these patients will have additional polyps.

Flexible Sigmoidoscopy

Specific instructions for reporting flexible sigmoidoscopy have been added to the section guidelines. Report  flexible sigmoidoscopy for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure.

Report flexible sigmoidoscopy for endoscopic examination of a patient who has undergone resection of the colon proximal to the sigmoid (e.g., subtotal colectomy) and has an ileo-sigmoid or ileo-rectal anastomosis. New codes for the flexible sigmoidoscopy family include endoscopic .

CPT Code Short Description Summary of Changes

45330 Flexible sigmoidoscopy Editorial: “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).”

45331 Biopsy Not separately reportable with EMR code 45349 for the same lesion.

45332 Foreign body(s) removal “Foreign body(s)” replaces “foreign body.” 

45333 Hot biopsy Bipolar cautery was deleted as an example.

45334 Control of bleeding “Any method” replaces previous examples. Not separately reportable with injection or banding of hemorrhoids described by 45335, 45350 for same lesion

FLEXIBLE SIGMOIDOSCOPY

45330 45330 Flexible sigmoidoscopy Editorial: “Including collection of specimen(s) by brushing or washing, when performed” replaces “with or without collection of specimen(s).”

45331 45331 Biopsy Not reportable with 45349 for the same lesion.

45332 45332 Foreign body removal “Foreign body(s)” replaces “foreign body.” Use 76000 if fluoroscopic guidance is performed.

45333 45333 Hot biopsy Bipolar cautery was deleted as an example.

45334 45334 Control of bleeding “Any method” replaces previous examples. Not separately reportable with injection or banding of hemorrhoids described by 45335, 45350 for same lesion.

45335 45335 Submucosal injection Not separately reportable with control of bleeding or endoscopic mucosal resection described by 45334, 45349 for the same lesion.

45337 45337 Decompression New language clarifies decompression for pathologic distention, such as volvulus or megacolon.

Includes placement of decompression tube when performed. Report only once per session.

45338 45338 Snare Not separately reportable with endoscopic mucosal resection described by 45349 for the same lesion.

45339 45346 Ablation Code 45339 has been deleted. 

New code 45346 includes balloon dilation, guide wire insertion and ablation. Not separately reportable with dilation code 45340 for the same lesion.

Sigmoidoscopy, flexible

* 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) A 0.96 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple A 1.15

* 45332 Sigmoidoscopy, flexible; with removal of foreign body(s) A 1.79

* 45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps A 1.79

* 45334 Sigmoidoscopy, flexible; with control of bleeding, any method A 2.73 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance A 1.46

* 45337 Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed A 2.36 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique A 2.34 D45339 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique D D 

Sigmoid/Colon Sigmoidoscopy

* diagnostic-45330-APC 146 ? with biopsy(s) or cold forceps removal-45331-APC 146 ? with snare removal-45338- APC 147

* with hot or cautery 45333- APC 147 ? not amenable to hot or snare… – 45339-APC 147 (APC 146 $299.34) (APC 147 $525.41)

CPT Code Procedure Description Facility Payment (National Medicare Avg)¹ APC  Facility Payment  (National Medicare Avg)² Fee When Procedure Is Performed in Hospital or ASC (National Medicare Avg)³ Fee When Procedure Is  Performed in Office
(National Medicare Avg)³ 44388 

Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate
procedure) $420.93
5312
 $752.76
 $170.18
 $359.71 

44389 Colonoscopy through stoma; with biopsy, single or multiple $420.93
5312
 $752.76
 $186.66
 $453.58

45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) $135.76
5311
 $492.45
 $58.40
 $169.82 

45331 Sigmoidoscopy, flexible; with biopsy, single or multiple $275.37
5311
 $492.45
 $75.60
 $260.83 

45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) $420.93
5312
 $752.76
 $200.28
 $386.22

45380 Colonoscopy, flexible; with biopsy, single or multiple $420.93
 5312
 $752.76
 $217.12
 $477.59
  
Flexible Sigmoidoscopy (45331 – 45347)

Colonoscopy (45379 – 45398, 52 Modifier)

Colonoscopy (45379 – 45398, No Modifier) 

CPT book –

Proctosigmoidoscopy- involves examining the rectum and sigmoid colon. 

45300 - 45327

Sigmoidoscopy- involves examining the entire rectum and sigmoid colon and may include examining a portion of the descending colon.

45330 - 45345

Colonoscopy- involves examining the entire colon, from the rectum to the cecum, must include the proximal colon to the splenic flexure, and it may include the terminal ileum. 
45355 - 45392

Colonoscopy vs. Sigmoidoscopy

Lengths of:

• Rigid sigmoidoscope is 25 cm long

• Flexible sigmoidoscope is 50 cm long

• Flexible colonoscope is 200 cm long

Definitions listed in CPT

Sigmoid/Colon

Sigmoidoscopy

* diagnostic-45330-APC 146 ? 

with biopsy(s) or cold forceps  removal-45331-APC 146

* with snare removal-45338- APC 147

* with hot or cautery 45333- APC 147

* not amenable to hot or snare… – 45339-APC 147

(APC 146 $299.34) 

(APC 147 $525.41)

Colorectal Endoscopy

* There are three types of colorectal endoscopy: (1) rigid sigmoidoscopy, (2) flexible sigmoidoscopy and (3) colonoscopy. Rigid sigmoidoscopy permits examination of the lower six to eight inches of the large intestine. In flexible sigmoidoscopy, the lower one-fourth to one-third of the colon is examined. Neither rigid nor flexible sigmoidoscopy requires medication and can be performed in the doctor's office.

* Colonoscopy uses a longer flexible instrument and usually permits inspection of the entire colon. Bowel preparation is
required, and sedation is often used. 

* The colon can also be indirectly examined using the barium enema x-ray technique. This examination uses a barium solution to coat the colon lining. X-rays are taken, and unsuspected polyps are frequently found. 

Case Study - Question

1. Colonoscopy with removal of tumor by snare or bipolar cautery 45384

2. Gastroscopy with biopsy single or multiple 43239

3. Proctosigmoidoscopy with ablation 45339

4. Colonoscopy with removal of tumor by snare technique 45385

Incomplete Colonoscopy

Physician billing: See Medicare Pub 100-4, Chapter 18, Section 60.2

Incomplete or interrupted colonoscopies:

The inability to extend beyond/proximal to the splenic flexure

• Applies to diagnostic and screening

• Medicare value = same as sigmoidoscopy

• When procedure is not completed due to an  adverse event.

• Example: Hypotensive episode

• 45378-53

• G0105-53

CPT states: “For an incomplete colonoscopy with full preparation for a colonoscopy, use a colonoscopy code with modifier 52 and provide documentation” 

Colorectal Cancer Screening – HCPCS Codes

Colorectal cancer screening

• Colonoscopy

• G0105 – high risk pt

• G0121 – non-high risk pt

• Flexible sigmoidoscopy – G0104

• Both have frequency limitations

 “If during a screening colonoscopy, a lesion or growth is removed, biopsied, …, the appropriate “diagnostic” procedure code should be billed and paid rather than code the screening code.

Reporting Examination of the Distal Defunctionalized Colon

CPT provides guidance on how to code for both endoscopic examination of the colon that remains above a stoma (colostomy) and, at the same time, examination of the bypassed or defunctionalized colon. 

If a patient has a colostomy, an exam from stoma to cecum would entail a colonoscopy through stoma (44388 series), and examination of the retained portions of the colon are coded with an anoscopy, proctosigmoidoscopy or flexible sigmoidoscopy code, as appropriate.

QUESTION: What are preventive colorectal cancer (CRC) screening services?

ANSWER: Preventive colorectal cancer screening services include CRC screening tests, such as fecal occult blood test (FOBT), fecal immunochemical test (FIT), flexible sigmoidoscopy, colonoscopy, CT colonography, or CologuardTM .

If a patient undergoes a CRC screening test by another health-care professional and an abnormality (e.g. positive test) is found that prompts referral for a colonoscopy, for Medicare, the colonoscopy is no longer a screening procedure and is no longer a preventive service.

For Medicare, this means that the patient is now responsible for the co-pay and deductible for the diagnostic colonoscopy, as it is not appropriate to code Z12.11 or Z12.12 for the colonoscopy. 

Note that CT colonography is not a covered service for CRC screening for Medicare. Cologuard is a covered service for Medicare beneficiaries.

For commercial payors, check the medical policy to see whether CT colonography and/or Cologuard are covered services for CRC screening. Check the summary plan description (SPD) and/or payor policy to see if a colonoscopy performed in an asymptomatic patient with a positive FOBT, FIT, Cologuard, flexible sigmoidoscopy or CT colonography is or is not still a preventive service (with waiver of financial responsibility).  

Personal or inherited risk of polyposis syndromes:

X Family history of familial adenomatous polyposis (FAP):

• Individual is a genetic carrier:

* Annual flexible sigmoidoscopy or colonoscopy, beginning at age 10 to 15.

• Genetic status is unknown:

* Annual flexible sigmoidoscopy or colonoscopy, beginning at age 10 to 15, until age 24 then:

* Repeat every two years until age 34.

* Repeat every three years until age 44.

* Then every three to five years thereafter.

• Individual is not a carrier:

n Average-risk screening should occur

Lower Endoscopy Definitions

• Proctosigmoidoscopy is the examination of the rectum and may include examination of a portion of the sigmoid colon

• Sigmoidoscopy is the examination of the entire rectum, sigmoid colon and may include examination of a portion of the descending colon

• 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 or colon-small intestine
anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis

CPT Error:  Report flexible sigmoidoscopy (45330-45347) for endoscopic examination during which the endoscope is not
advanced beyond the splenic flexure  

THIS IS RIGHT BELOW THE INSTRUCTION TO ADD THE 52 AND 53  MODIFIER PARAGRAPHS AND CONTRADICTS THE PREVIOUS INSTRUCTION.  CPT IS GOING TO RELEASE A FIX TO THIS PARAGRAPH INDICATING THAT THE INTENT WOULD BE A FLEXIBLE SIGMOIDOSCOPY

• Report ileoscopy through stoma (44380-44384) for endoscopy examination of a patient who has an ileostomy.

• Report  colonoscopy through stoma (44388-44408) for endoscopic exam of a patient who has undergone segmental resection of the colon (eg, hemicolectomy, sigmoid colectomy, low anterior resection) and has a stoma

• Report proctosigmoidoscopy, sigmoidoscopy or anoscopy, as appropriate for endoscopic exam of a defunctionalized rectum or
distal colon in a patient who has undergone colecotmy, in addition to colonoscopy through stoma or ileoscopy through stoma, if appropriate

• Report flexible sigmoidoscopy (45330-45347) for exam of a patient who has undergone resection of the colon proximal to the sigmoid (subtotal colectomy) and has ileo-sigmoid or ileo-rectal anastomosis)

Colon/Rectum Cancer Work-up

• Sigmoidoscopy

• Colonoscopy

• Biopsy 

Through sigmoidoscopy or colonoscopy, a scope is inserted into the colon to visualize the lining. This may identify tumor size and location. Sigmoidoscopy and colonoscopy are used for screening as well as work-up for cancer of the colon/rectum. Biopsy may be performed at the time of sigmoidoscopy or  colonoscopy to any suspicious lesions. Biopsy will identify the histology, behavior, and grade of the tumor.

1 comment:

  1. Hello, Great blog nice n useful information , it is very helpful for me , I realy appreciate thanks for sharing. I would like to read more information thanks.
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