Basics about Colorectal Cancer
American Cancer Society ranks colorectal cancer is the third most common cancer in the United States.
• Estimated 100K cases every year
• Over 43,000 cases of rectal cancer
• Risk in men one in 23 and one in 25 for women
Colon cancer is preventable
• When detected early—less likely to cause death
• Routine screening is key!
• Finding any cancer early allows for:
• More treatment options
• More successful outcomes
American Cancer Society recommends screenings for individuals at average risk
• Age 45
• Age 50 for the CDC and most other authorities
Know the Rules for Screening Services
• Medicare will cover colorectal screening services once the beneficiary turns 50
• For average risk screening covered every 10 years
• For high risk shorter frequency
• Medicare Claims Processing Manual, Chapter 18, Section 60
High Risk Patients have these characteristics:
• Close family member who has had colorectal cancer or an adenomatous polyp
• Family history of:
• Adenomatous polyposis
• Hereditary nonpolyposis colorectal cancer
• Personal history of:
• Adenomatous polyps
• Colorectal cancer
• Inflammatory bowel disease
A few G codes for screening services:
G0121-average risk colonoscopy
G0105-high risk colonoscopy
G0104- flexible sigmoidoscopy
G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
Billed for patients that are receiving routine colon cancer screenings
- Service covered once every 10 years
- NOT before 47 months of a previous screening service
- Bill if there were no findings
- Z12.11 (Encounter for screening for malignant neoplasm of colon)
G0105 (Colorectal cancer screening; colonoscopy on individual at high risk)
Covered once every 2 years for high risk patients
High risk may receive first screening at a younger age
- Z86.010 (Personal history of colonic polyps)
• Z85.038 (Personal history of other malignant neoplasm of large intestine)
• Z80.0 (Family history of malignancy neoplasm of digestive organs)
G0104 (Colorectal cancer screening; flexible sigmoidoscopy)
Covered once every 48 months
- Unless the beneficiary does NOT meet the criteria for high risk
• AND
• The patient has had a screening colonoscopy within the
preceding 10 years
G0104 may be covered ONLY AFTER at least 119 months (Nine years and 9 months) have passed since the last screening colonoscopy (G0121)
Gastroenterologists should ensure that patients referred to them for colorectal screenings are asymptomatic
• In many cases patients are referred for a screening, but have symptoms
• Those services should be billed as diagnostic
Coding Scenarios
Scenario 1:
Patient presents with blood in the stool and the physician schedules a colonoscopy.
• NEVER report colorectal screening codes for qualifying diagnostic service
• The screening codes are used when a patient is asymptomatic
• Blood in stool initiates a diagnostic colonoscopy and not a screening
Bill the appropriate CPT code for the diagnostic service
• For example:
• 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure))
• 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) for the diagnostic service
If during screening colonoscopy provider finds something
• Bill the appropriate diagnostic CPT® code—NOT the screening code
• Different payers may require different dx codes
• Most cases—report screening diagnosis code AND the diagnostic code
• Most payers require a modifier appended
• If the provider identifies a problem during a screening colonoscopy
• Drop the G code and use a CPT code
• For example:
• 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure))
• With a modifier indicating that the case started out as a screening service and turned diagnostic
Scenario 2:
Patient was found to have diverticulosis during a screening colonoscopy
• Select CPT 45378
• ICD-10 codes Z12.11 and K57.30 (Diverticulosis of large intestine without
perforation or abscess without bleeding)
• Append modifier PT
Provider sends any specimens to a pathologist for review
• Check the path report for a final diagnosis
• Be as accurate as possible—even if that means double checking before sending a claim to the payer
• Keep in mind: ICD-10-CM codes are specific to the location of the cancer.
Modifier PT
• PT (Colorectal cancer screening test; converted to diagnostic test or other procedure)
• Use when a colorectal cancer screening test converts to a diagnostic or therapeutic procedure
• Tips
• Modifier PT waives the deductible
• Codes associated with this modifier fall in the Surgery section of CPT®
Modifier 33
• 33 (Preventative Screening)
• NO NOT use modifier 33 for services that are inherently screening
• Example screening mammogram
• Preventive services have an A or B rating
• Does the service have a substantial or moderately substantial benefit to the patient
• Tips
• Medicare and some other payers do not recognize modifier 33
• Medicare pays for preventive services that are specifically legislated
• G codes
• ONLY append modifier 33 to a CPT® code
Effective Jan. 1, 2023 Medicare coverage policies for colorectal cancer screenings will change. Specifically, as specified in 42 CFR 410.37(k), for dates of service on or after Jan. 1, 2023, colorectal cancer screening tests include a follow-up screening colonoscopy after a Medicare covered non-invasive stool-based colorectal cancer screening test returns a positive result. Therefore, when a Medicare patient presents for a follow-up colonoscopy due to a positive stool-based colorectal cancer-screening test, the colonoscopy would be a continuation of the preventative service and not considered a diagnostic exam.
Resources
• www.SuperCoder.com
• https://www.cdc.gov/
• https://www.cancer.org/
• https://www.cologuardtest.com/
• https://www.asge.org/home/for-patients/resourcesfor-national-colorectal-cancer-awareness-month
• https://myriad.com/
