Wednesday, 4 January 2017

Medicare CPT Code Description 45385

Colonoscopy Billing tips - cpt 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: 

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

The colonoscopy procedure code:

o 45385 with modifier 33 indicating that the service was preventive

 The screening diagnosis code:

o V76.51 AND The diagnosis code for the condition found: o 211.3


Diagnostic colonoscopy performed due to signs or symptoms, or to ruleout or confirm a suspected diagnosis

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. 

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. 

45385

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.

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. 

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.

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.

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.

Use 45385 for Total Polypectomies

Gastroenterologists usually perform a total or entire polypectomy with an electrocautery snare — a heated wire loop that shaves off the polyp. When the physician uses the snare technique during a total polypectomy, you should report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Rule of thumb: No matter how many tumors, polyps, or lesions the doctor treats by the similar techniques, remember that the words “tumor(s), polyp(s), or other lesion(s)” in the descriptions of 45383, 45384, and 45385 signal that you’re also restricted to reporting only one of these codes per colonoscopy.

Two polyps, two techniques:

Your gastroenterologist used the snare technique to remove the first polyp and hot  biopsy forceps to remove and control bleeding during the second polyp removal. As long as documentation supports the need for using different techniques on different polyps, you should report both 45385 and 45384.

Billing and Coding Guideline for CPT 45385

45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique (add modifier PT for Medicare or modifier 33 for commercial payers when screening was indication or finding was discovered during screening procedure)

Anthem Blue Cross and Blue Shield Central Region Clinical Claim Edit

Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below.

Description CODE RULE CODE

45384 Incidental 45385
45384-59 Separate Reimbursement 45385

Rationale

Anthem Central Region bundles 45384 as incidental with 45385. Based on the National Correct Coding Initiative Manual, Chapter 6, it states: “If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered should be reported.” Therefore, if 45384 is submitted with 45385—only 45385 reimburses.

Anthem Central Region does not bundle 45384-59 with 45385. If one polyp is removed in one area of the intestines (45384) and another/different polyp is remove in a different part of the intestines, append modifier 59 to 45384 (45384-59) and both procedures reimburse separately.

Anthem Central Region does not bundle 45384 with 45385. Based on CPT Assistant:

“From a CPT perspective codes 45384 and 45385-51 can be reported together on the same date of service. Both codes can be reported because two separate lesions were removed by two different techniques.”

The National Correct Coding guide, does not list code 45384 as being a component to code 45385. Therefore, if 45384 is submitted with 45385—both reimburse separately.

Screening colonoscopy during which a polyp in  the large intestine is found, removed with a snare and sent to pathology. The colonoscopy procedure code: o 45385 with modifier 33 indicating that the service was preventive The screening diagnosis code: o V76.51 AND The diagnosis code for the condition found: o 211.3

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.

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 .

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