Avoid Colonoscopy Billing Mistakes

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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
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• 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.
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• 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 payors requirements.

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Avoid Colonoscopy Billing Mistakes

• 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).
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• 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.

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Avoid Colonoscopy Billing Mistakes

• 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.
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• 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.

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Avoid Colonoscopy Billing Mistakes

• 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.
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• 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.

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Avoid Colonoscopy Billing Mistakes

• 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)
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• 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!