CPT code and Description
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy
SUMMARY OF CHANGES: The method for calculating payment for discontinued procedures is being revised. New payment rates will apply when modifier 53 (discontinued procedure) is appended to codes 44388, 45378, G0105, and G0121.
GENERAL INFORMATION
A. Background: Prior to calendar year (CY) 2015, according to Current Procedural Terminology (CPT) instruction, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Physicians were previously instructed to report an incomplete colonoscopy with 45378 and append modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy.
In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states, “When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is
unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.” Therefore, in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) has applied specific values in the Medicare physician fee schedule database for the following codes: 44388-53, 45378-53, G0105-53, and
G0121-53.
B. Policy: Effective for services performed on or after January 1, 2016, the Medicare physician fee schedule database will have specific values for codes 44388-53, 45378-53, G0105-53, and G0121-53. Given that the new CPT definition of an incomplete colonoscopy also includes colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum, CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. Incomplete colonoscopies are reported with the 53 modifier. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.
Incomplete Colonoscopies (Codes 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 modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.
• HCPCS G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.
G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy
Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below. For claims with dates of service on or after January 1, 2002, contractors pay for screening flexible sigmoidoscopies (HCPCS G0104) for beneficiaries who have attained age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in §1861(aa)(5) of the Social Security Act (the Act) and in the Code of Federal Regulations (CFR) at 42 CFR 410.74, 410.75, and 410.76) at the frequencies noted above. For claims with dates of service prior to January 1, 2002, Medicare Administrative Contractors (MACs) pay for these services
under the conditions noted only when a doctor of medicine or osteopathy performs them.
For services furnished from January 1, 1998, through June 30, 2001, inclusive:
• Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was performed).
For services furnished on or after July 1, 2001:
• Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §60.3 of this chapter) and he/she has had a screening colonoscopy (HCPCS G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (HCPCS G0121).
NOTE: If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth; the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal along with modifier –PT should be billed and paid rather than HCPCS G0104.
When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances (see chapter 12, section 30.1), Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes. The Medicare physician fee schedule database has specific
values for codes 44388-53, 45378-53, G0105-53 and G0121-53. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure as long as coverage conditions are met. This policy is applied to both screening and diagnostic colonoscopies. When submitting a claim for the interrupted colonoscopy, professional providers are to suffix the colonoscopy code with a modifier of “–53” to indicate that the procedure was interrupted. When submitting a claim for the facility fee associated with this procedure, Ambulatory Surgical Centers (ASCs) are to suffix the colonoscopy code with modifier “–73” or “–74” as appropriate. Payment for covered screening colonoscopies, including that for the associated ASC facility fee when applicable, shall be consistent with payment for diagnostic colonoscopies, whether the procedure is complete or incomplete.
Note that Medicare would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the contractor to document the incomplete procedure.
HCPCS G0121 - Colorectal Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk - Applicable On and After July 1, 2001
Effective for services furnished on or after July 1, 2001, screening colonoscopies (HCPCS G0121) performed on individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §60.3 of this chapter) may be paid under the following conditions:
• At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered HCPCS G0121 screening colonoscopy was performed.)
• If the individual would otherwise qualify to have covered a HCPCS G0121 screening colonoscopy based on the above but has had a covered screening flexible sigmoidoscopy (HCPCS G0104), then he or she may have covered a HCPCS G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered HCPCS G0104 flexible sigmoidoscopy was performed.
NOTE: If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal along with modifier –PT should be billed and paid rather than HCPCS G0121.
Colonoscopy – CPT Codes 45378-45398, G0105, G0121
The American Society for Gastrointestinal Endoscopy (ASGE) works to ensure that adequate methods are in place for gastroenterology practices to report and obtain fair and reasonable reimbursement for procedures, tests and visits. To assist practices in understanding and implementing GI-specific coding, ASGE has developed coding sheets. The purpose of the coding sheet is to provide a high-level overview to support practices in there coding and reimbursement for 2018.
What is a Colonoscopy?
It is an 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.
The CPT© codes in this series identify services performed during Colonoscopy
HCPCS Codes for Colonoscopy
HCPCS Code Code Descriptor
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
Gastroenterology Coding: Screening Versus Diagnostic Colonoscopy
To define the procedure, a colonoscopy is the examination of the entire colon from the rectum to the cecum, and it may include examination of the terminal ileum (small intestine). With that being said, there are two types of colonoscopies: screening and diagnostic. Medicare has specific guidelines for screening and diagnostic colonoscopies. Other payers may have very specific criteria for both types of colonoscopies as well.
Medicare defines these two types as:
1. Screening – used for patients who have:
• No family history of colon cancer or colon polyps
• No personal history of colon cancer or polyps
• No symptoms before the procedure (abdominal cramping, blood in the stool, weight loss, anemia, vomiting)
2. Diagnostic – used for patients who have:
• Family history of colon cancer or polyps
• Personal history of colon cancer or polyps
• Symptoms before the procedure (abdominal cramping, blood in the stool, weight loss, anemia, vomiting)
• Previous colonoscopy(ies) with findings of polyps, colon cancer, diverticulitis, etc.
Medicare also defines what they consider to be high risk for colorectal cancer as an individual with:
• A close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp
• A family history of familial adenomatous polyposis
• A family history of hereditary nonpolyposis colorectal cancer
• A personal history of adenomatous polyps;
• A personal history of colorectal cancer; or
• Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis
Medicare uses HCPCS codes to bill for screening colonoscopies. For a patient of typical risk, the screening procedure is reported with HCPCS code G0121; for a
patient at high risk, it is reported with HCPCS code G0105. Providers should review the policies of their insurance payers to be certain which coding system is
used, especially for Medicare Advantage plans offered by commercial insurers.
Per the 2019 AMA CPT Professional Edition guidelines:
When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colonsmall intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.
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 and provide appropriate documentation.
For colonoscopy through stoma, see 44388-44408.
So, the first step to coding a colonoscopy is to determine if it is a screening or diagnostic colonoscopy. If the patient has had any signs or symptoms such as
abdominal pain, weight loss or rectal bleeding, then it is not a screening but rather a diagnostic (symptomatic) colonoscopy. Also, if the patient has had
previous findings such as polyps or diverticulitis, then it is not a screening colonoscopy.
Aside from the CPT coding guidelines, if you’re wondering what the current Medicare reimbursement rates are for selected GI services, GI.org has a helpful
chart.
Keeping track of gastroenterology code changes should not fall solely on you or your staff. You should have tools in place like a gastroenterology EHR system that
can help in the process.
providing the correct procedure codes to report colonoscopies continues to cause confusion for the professional coder. The American Medical Association (AMA) provides the Common Procedural Terminology (CPT) codes used to report outpatient procedures for hospitals and physicians. Medicare adds additional codes in the HCPCS Healthcare Procedure Coding System). HCPCS includes both CPT, which is HCPCS Level I, and CMS-developed HCPCS Level II codes. The HCPCS codes are required for all Medicare outpatient hospital services, if they are available, unless specifically excepted in Medicare manual instructions. Let us take a look at some typical colonoscopy coding scenarios, and the CPT and HCPCS codes that should be reported.
Screening colonoscopy
AHA Coding Clinic provides guidance in assigning the principal or first-listed diagnosis code when the physician documents that the colonoscopy is performed for screening purposes only. Code V76.51 is used first and any findings such as polyps, diverticulosis, or hemorrhoids are listed second; see Coding Clinic, First Quarter 1999 Page: 4. CPT codes are reported based on the procedure documented, and whether the patient is Medicare. If the patient is not Medicare, the appropriate CPT, (HCPCS Level I) code is assigned. If the patient is Medicare and no other procedures, such as a polypectomy or biopsy are performed, then either code G0105 or G0121,
(HCPCSL Level II) codes are assigned. G0105 is assigned if the patient qualifies as high risk using the following criteria:
* A personal history of colorectal cancer or
* A family history of familial adenomatous polyposis or
* A family history of hereditary nonpolyposis colorectal cancer or
* A personal history of adenomatous polyps or
* Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis or
* A close relative (sibling, parent, or child) has had colorectal cancer or an adenomatous polyp.
HCPCS code G0121 is assigned if the patient does not qualify as high risk.
Screening colonoscopy with polypectomy
If the colonoscopy starts as a screening, but the physician finds polyps and performs a polypectomy, the principal or first-listed diagnosis code remains as V76.51. The polyp is reported as a secondary diagnosis code. The procedure reported will depend on the documentation and will include only the CPT, Level I HCPCS code(s). Medicare also requires the modifier PT to be added to the procedure code, when the screening colonoscopy becomes a diagnostic colonoscopy. Use of this modifier will allow the Medicare patient to have the deductible waved.
Colonoscopy with different polypectomy techniques
When the colonoscopy includes more than one polypectomy technique, each technique may be reported separately if performed on different polyp sites. For example the physician performs a cold forceps polypectomy on a polyp in the descending colon, a polypectomy using snare in the rectum, and a polypectomy using hot forceps in the rectum.
Each procedure is reported using modifier 59 for the second two; see Coding Clinic for HCPCS - Third Quarter 2006 Page: 4. If two techniques are used on the same polyp, such as a snare removal followed by hot cautery, only the hot cautery should be reported; see CPT Assistant January 2004, pages 5-7.
Colonoscopy with tattooing
Occasionally, the physician injects ink to identify a polypectomy or other suspicious sites in the colon when performing the colonoscopy. CPT code 45381, colonoscopy with submucosal injection, should be reported in addition to the polypectomy or other procedure; see CPT Assistant, June, 2010, page 4. A separate procedure modifier 59 is not required.
Colonoscopy with upper endoscopy
Quite often a colonoscopy is performed either just prior to, or just following an upper endoscopy, or esophagogastroduodenoscopy, (EGD). When this situation occurs, both the code for the colonoscopy and the EGD are reported. Modifier 59 is not required as the procedures are performed in different body systems. A high percentage of modifier 59 use could prompt a focus review by an outside agency.
It is important to understand the colonoscopy coding guidelines and associated procedures for both coding compliance and to obtain the correct reimbursement due to the facility. Performing routine audits to check the coding of this procedure will help to ensure proper coding.
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