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Detailed Guide of CPT Codes For Colonoscopy Coding

Colonoscopy coding was always challenging for health professionals and medical coders. 

Especially during the primary diagnosis of the patients, the process seems difficult. But colonoscopy coding with precision is necessary to come up with an accurate report of the present health condition. 

The colonoscopy procedures are performed by surgeons and specialists to examine for potential malignancy. All of these need coding for further diagnosis. 

After the primary diagnosis with coding, the patients undergo other procedures.

In this blog post, we will cover everything related to colonoscopy coding, including diagnostic colonoscopy, screening colonoscopy, surveillance, and therapeutic colonoscopy.

The sections will also help you understand the screening vs diagnostic colonoscopy. But before we head forward, let’s start with the basics.

Overview on Colonoscopy

Colonoscopy is a medical procedure performed by specialised surgeons. Here, the specialist used a colonoscope to examine the rectum and proceed to the colon section. 

This procedure helps the doctor diagnose ulcers, polyps, swollen and irritated tissue, and cancer. It is an effective procedure to examine the complete large intestine or colon.

The possibility of polyps or colorectal cancer can be found easily at the initial stage with the help of a colonoscopy. 

Remember that Polyps are minor growths, and it is not cancerous tumour, but it has the potential to turn into cancer. The Colonoscopy test also helps to check out bowel problems such as bowel movement changes, bleeding, and other risky problems.

In this process, the surgeon inserts a long, tubular, and flexible tool called a colonoscope inside the patient’s anus. It lets them understand the complete lining of the colon. 

Digestive system diagram with colonoscopy coding guide

It will help the physician detect diseased conditions and abnormalities. These tests are performed as a preventative screening for colorectal cancer, for diagnostic and therapeutic purposes, and for surveillance reasons.

Moreover, there is a huge difference between diagnostic vs preventive colonoscopy. This is where you must understand the code of colonoscopies. If the codes are not known properly, it can become difficult to find out the exact health conditions and understand the encounter types.

What are the Types of Colonoscopy?

There are four major encounter types of Colonoscopy. The physician must have to find out the exact encounter type. Here, we bought a detailed overview of the colonoscopy types. 

The below sections will also help you know about the screening vs diagnostic colonoscopy coding.

Screening Colonoscopy

This type of colonoscopy is for asymptomatic patients where the signs and symptoms are usually absent. It is performed based on the patient’s gender, genetic history, medical history, age, and other factors based on medical guidelines. 

The screening colonoscopy is regularly performed on an asymptomatic patient to examine the possibility of colorectal cancer.

When the patient undergoes a screening colonoscopy to be diagnosed with a lesion or polyp, the primary diagnosis will take place under code Z12.11. 

This code displays the encounter type for screening for malignant neoplasm of the colon. Here, the medical coder should also report the findings or polyp along with other additional diagnosis codes.

So, in screening colonoscopy, the precision dx code should be reported irrespective of the findings during the examination. 

It must include the other procedures done to find the health conditions. In simple terms, the screening colonoscopy is a preventive procedure to ensure the patient is healthy.

When a patient should undergo screening colonoscopy?

  • Having no gastrointestinal symptoms – bleeding, pain, etc.
  • Age 45 and over.
  • No family history of GI ( Gastrointestinal ) disease, polyps, or cancer.
  • Not undergone a colonoscopy in the past 10 years.

Note : Patients must meet these criteria for screening colonoscopy. If the doctor finds additional requirements, he can go for a diagnostic colonoscopy which justifies the routine vs diagnostic colonoscopy process.

Diagnostic colonoscopy

A diagnostic colonoscopy is performed to investigate abnormalities. This procedure is preferred based on the signs and symptoms, family history, and conditions. 

This shows the difference between the colonoscopy diagnostic vs screening. Also, here, the symptoms will include physical signs such as rectal pain and bleeding.

The process is performed when the patient has such as rectal bleeding or pain. This test confirms the suspected health condition or rules it out. 

The diagnostic colonoscopy ICD 10 is Code 45378. When a patient has possible symptoms and a strong genetic history of colon cancer should undergo a diagnostic colonoscopy which is not required for screening colonoscopy.

When a patient should undergo a diagnostic colonoscopy?

After you understand what is a diagnostic colonoscopy, below are the symptoms to be aware of.

  • Persistent abdominal pain
  • Iron-deficiency
  • Rectal bleeding or bleeding while passing stool
  • Bowel movement changes for more than a few days
  • Family history of colon cancer or polyps

Therapeutic Colonoscopy

The therapeutic colonoscopy is performed when the abnormalities are examined and treated for the purpose of tumour ablation, biopsy, and other therapies. 

In this process, the specialist takes action to treat and correct the health or disorder. The procedure aids in removing polyps, dilating stricture (a narrowed area), and stopping bleeding from the rectal lining. 

This therapeutic method usually starts with a diagnostic exam. The endoscopist reports suggest using the colonoscopy diagnostic CPT code 45379-45392 for the diagnostic or therapeutic procedure performed.

Therapeutic colonoscopy is useful for treating many disorders and diseases from the root. Physicians find this procedure very helpful in treating patients suffering from diagnosing gastrointestinal diseases. 

For example, treating colon cancer and inflammatory bowel disease is highly preferred. This therapy also prevents colon cancer from treating and removing potential polyps from the root.

The therapeutic procedure includes polypectomy, injecting medications, placing stents, removal of blockages, sealing wounds, and treating tissues with laser therapy.

When the patient should undergo therapeutic colonoscopy?

  • Signs of abdominal pain
  •  Rectal bleeding
  • Chronic diarrhoea
  • Other intestinal problems.

Surveillance Colonoscopy

A surveillance colonoscopy procedure is done for asymptomatic patients. It is similar to the screening colonoscopy.

But, the difference is the treatment is done for patients with a history of gastrointestinal disease, colon cancer, or colon polyps. In simple terms, it is a screening test with various frequency guidelines and diagnostic colonoscopy coding.

Surveillance is used to describe the previous visit for colonoscopies. When the patient has previously undergone polypectomy or removal of colon polyps and now suspects additional polyps should go for this procedure which is coded with Z12.11. 

In this process, the growth of extra polyps or recurrence is examined. Anyways, it comes under the first listed primary diagnosis, i.e., the encounter of screening for malignant neoplasm of the colon.

As surveillance colonoscopies are likely similar to screenings, the coder has to be very cautious. This is because sometimes the doctor may document a “surveillance” colonoscopy, but in fact, he might have performed a follow-up colonoscopy. 

This is why the coder must read and follow the information very carefully in the medical record.

When patients undergo surveillance colonoscopy?

  • Patients with high-risk criteria must undergo a surveillance colonoscopy at 3 years.
  • Colonoscopy should be performed on CRC resection patients one year after surgery and every three years thereafter.
  • Patients with 1–2 adenomas of <10 mm must undergo surveillance colonoscopy in 7 to 10 years.
  • For patients with 3–4 adenomas of  <10 mm, surveillance should be done in 3–5 years.

Other Types of Colonoscopy

Follow-up Colonoscopy/Examination

The physician performs a follow-up examination when he detects a potentially malignant lesion or neoplasm. This can further have chances to turn into a malignant transformation.

For example, an individual who had previously undergone a colonoscopy or had a polypectomy a few months ago for an adenomatous polyp visits the physician for a follow-up colonoscopy. This is particularly done to check for recurrence, coded with Z09.

Code Z09 shows an encounter of follow-up examination after the completion of treatment for other possible disease or disorder conditions other than the malignant neoplasm. 

But, in case the follow-up colonoscopy is conducted for a patient after the removal of malignancy, then it will be coded with Z08. The code Z08 states an encounter for follow-up colonoscopy after the treatment completion for a malignant neoplasm that may be reported at the first listed code.

Outpatient Colonoscopy

A patient undergoes outpatient colonoscopy due to noticeable symptoms or results of findings during primary diagnosis. 

When the major cause is identified or found based on the symptoms the physician notes, it will be the primary diagnosis. 

Moreover, if the patient notices bowel movement changes and the endoscopy findings show severe sigmoid diverticulosis, the primary diagnosis will still be considered. It is stated unless the doctor specifies that symptoms are due to the finding of diverticulosis.

But, when the physician specifies that the diverticulosis is the aetiology of the symptoms or postoperative diagnosis, then diverticulosis will be considered the primary diagnosis.

What is the PT modifier on colonoscopy?

The PT modifier on colonoscopy is appended or attached to the CPT code. This is performed by the medical coder when the colorectal cancer screening test has been converted into a diagnostic test or other procedure of colonoscopy. 

Therefore, the addition or attachment of PT to the CPT diagnostic colonoscopy indicates in the report that the scheduled screening/routine colonoscopy has been changed to a diagnostic or therapeutic colonoscopy.

You might feel confused about when does a screening colonoscopy become diagnostic. Yes, it is common for patients to get confused about why the conversion was done and why it was necessary. 

The physician, when encountering necessities or noticing possible symptoms or signs, changes the screening colonoscopy immediately into a diagnostic or therapeutic colonoscopy.

The coder must report an accurate CPT code with the PT modifier for changing the procedure into a diagnostic colonoscopy. 

It should be carefully submitted with an appropriate diagnosis report to justify the procedure. For example, coded with Z80.0, which states a family history of malignant neoplasm in the digestive organs.

Below are the steps that the coder follows to convert the screening colonoscopy into a diagnostic colonoscopy which will let you know the colonoscopy routine vs diagnostic method conversion.

  • The coder chooses the accurate CPT codes for colonoscopy that describe or justifies the procedure that the patient has undergone or attempted by the physician.
  • Next, the coder appends or adds the PT modifier to the CPT code. The modifier attached then indicates the conversion of screening colonoscopy to diagnostic colonoscopy.
  • Then an accurate ICD-10 diagnosis code indicates that it was a screening test. At the same time, the diagnosis code Z80.0 will indicate a family history of malignant cancer.

A physician can take any potential and justified reason to convert the test. This also indicates screening of beneficiaries at high risk.

Also, when the doctor diagnoses a mass that needs a biopsy or examines a polyp, in such cases, the colonoscopy is indicated as diagnostic at that particular point. This also states the variation and difference between diagnostic colonoscopy vs screening colonoscopy.

What are the right colonoscopy codes used for the patients for CRC screening?

Different colonoscopy coding is used for patients choosing to undergo colonoscopy for CRC -colorectal cancer screening.

For commercial and Medicaid patients, CPT code 45378 is used. The code states colonoscopy, proximal to the splenic flexure, flexible, diagnostic, and maybe with or without specimen collection. It is performed by brushing or washing, with or without colon decompression.

The HCPCS (Healthcare Common Procedural Coding System) code used for Medicare beneficiaries who have chosen colonoscopy for CRC screening is G0105. 

This code states colorectal cancer screening for conducting colonoscopies on high-risk patients. HCPCS code G0121 that indicates CRC screening; to perform a colonoscopy on a patient who does not meet the criteria for high risk.

But, in case the patients have undergone removal of polyps or polypectomy removed, here are the accurate CPT codes for colonoscopy listed below based on the technique utilised.

  • 45380 – Colonoscopy, flexible, with biopsy performed, either single or multiple
  • 45384 – Colonoscopy, flexible, with one or multiple removals of polyps, tumours, and lesions with the help of hot biopsy forceps.
  • 45385 – Colonoscopy, flexible, tumours, polyps, or lesions removal by snare technique.
  • 45388 – Colonoscopy, flexible, with ablation – that indicates the destruction of tumours, polyps, or lesions. The procedure may involve medical processes such as pre and post-dilation, guided by wire passage.

Final Thoughts

Colonoscopy coding with precision helps to know the reason behind the encounter or the colonoscopy procedure conducted. It will let the patient know whether they have undergone preventive, therapeutic, diagnostic, follow-up, or surveillance colonoscopy. 

The right procedure code is selected based on the patient’s signs and symptoms, the potential risk for colorectal cancer, age, and insurance. The coder needs to be very accurate in stating the report’s details, which will be helpful for further follow-up.

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