Avoid Colonoscopy Billing Mistakes

Understanding the business side of medicine helps physicians run a successful practice. However, the business side of medicine is not part of the normal curriculum in training and fellowship programs. Physicians come out of training with the knowledge to treat patients but with little or no knowledge of how to get reimbursed for their services. We shared some guidelines which will help you to avoid colonoscopy billing mistakes.

Guidelines for Colonoscopy Billing Mistakes

Incomplete Colonoscopy

  • CPT codes used to define an incomplete colonoscopy (by CMS in the IOM at 100-4, Chapter 12, Section 30.1.B Incomplete Colonoscopies) are 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 a modifier. The choice of modifier depends on the payor’s requirements.
  • Failed colonoscopies may also be referred to as ‘incomplete.’ Sometimes the physician states the procedure was not completed due to a ‘poor prep.’ This occurs when the scope is not able to be advanced past the splenic flexure. Causes of this problem include incomplete preps, unusual patient anatomy, the patient has an obstructing lesion or the provider performing the procedure is inexperienced.

Successful Surgery

  • If the physician performing a colonoscopy attempts but fails to remove a polyp by snare technique, but he is successful at removing the polyp via another technique (such as hot biopsy forceps), only bill the CPT code for the technique/procedure which was successful (use code 45374 for a hot biopsy forceps polypectomy in this case).
  • For either a colonoscopy or EGD procedure, if a lesion is biopsied and then subsequently the same lesion is removed during the same operative session, code the removal of the lesion only, the biopsy would be considered incidental and not separately billable.
  • For either a colonoscopy or EGD procedure, if one lesion is biopsied and a separate lesion is removed using a different method, during the same operative session, code both the biopsy of the lesion and the removal of the separate lesion. Append a suitable modifier to the biopsy procedure if it is unbundled in the CCI unbundling edits.

Other Guidelines

  • Do not report a colonoscopy procedure code for an endoscopy performed with a sigmoidoscope on a patient with a normal length colon, even if the sigmoidoscope reaches proximal to the splenic flexure. A sigmoidoscope (an endoscope typically 65 centimeters in length) may be used for a colonoscopy only if the bowel is sufficiently short so that the entire colon may be examined, and such should be clearly documented in the clinical record.
  • Medicare guidance for the situation where a colonoscopy is scheduled as a screening procedure but a polyp is removed and/or a biopsy is taken is to not bill the G-code for a screening study but bill the appropriate CPT codes for the actual procedure(s) performed (45385, 45380-59, etc.). On the claim form, list the diagnoses with the screening diagnosis code first followed by the polyp or other applicable diagnosis code(s). If your Medicare intermediary specifically directs billing these procedures in another manner, follow its guidance.
  • The most specific ICD-10-CM code must be chosen and billed to its highest level of specificity. Submit this as the line diagnosis (linked to the procedure) on the claim. A complete list of applicable diagnosis codes will be available on the CMS website.

Documentation Requirement

  • Supportive clinical documentation evidencing the condition and treatment is expected to be documented in the clinical notes or procedure notes and be made available upon request from the MAC or other authorized CMS auditor.
  • Medical records need not be submitted with the claim unless modifier 22 is used; however, they must be furnished to Medicare upon request.
  • The medical records must support the medical reasonableness, necessity, and frequency of each diagnostic service supplied.
  • The medical record must substantiate the diagnosis listed on the claim form. The colonoscopy report must describe the following:
    • The maximum depth of penetration;
    • A description of any abnormal findings; and
    • Any procedures performed as the result of such findings (e.g., biopsy)

As mentioned earlier, physicians come out of training with the knowledge to treat patients but with little or no knowledge of how to get reimbursed for their services. You can outsource your medical billing to us. We are having a team of HIPAA-compliant experts with a clean claim submission rate of 95%. Get in touch with us!