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Distinguish between diagnostic and screening colonoscopies

APCs Weekly Monitor, November 30, 2007

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QUESTION: During a scheduled colonoscopy, the physician only reaches the sigmoid. Would you code this as a sigmoidoscopy or colonoscopy with modifier -74?

ANSWER:Refer to Transmittal AB-03-114, which Medicare published on August 1, 2003. First, identify whether the colonoscopy is diagnostic or screening. A diagnostic colonoscopy will include a current sign, symptom, or chief complaint that the patient experiences abdominal pain, rectal bleeding or change of bowel habits, for example. This will indicate the medical necessity of the procedure. A screening colonoscopy is defined as absent or without signs, symptoms, or a chief complaint (i.e., benchmark or high-risk indicators, such as, personal or family history of colorectal cancer or colon polyps). It is extremely important to understand the type of procedure that the physician intends to perform that day. Refer to your Fiscal Intermediary's current Local Coverage Determination for these procedures to concur that coding guidelines are maintained.

Consider the following scenario: The hospital schedules the patient for a diagnostic or screening colonoscopy; the physician preps the patient, and the physician or nurse administers conscious sedation services. Next, the physician inserts the scope to the sigmoid, but the exam is interrupted due to poor colon preparation. Transmittal AB-03-114 states that providers should report what was intended to be done with modifier -74. Therefore, depending on the type of scheduled colonoscopy, the correct CPT code is 45378-74 or G0105-74. Do not code to the extent, which is an ICD-9-CM procedure rule.

When you report modifier -74, Medicare says that you should report code V64.X as a secondary diagnosis. When you report this procedure with modifier -74, CMS will pay 100% of the triggered APC. Many times, the hospital will reschedule the patient in the future, and the physician will successfully perform the colonoscopy. Once that claim is submitted, CMS uses the Common Working File to monitor frequency of certain services to include screening colonoscopies. CMS will look at the previous claim with modifier -74 and will allow payment for the completed screening colonoscopy without penalties or denials.

Remember that hospitals should report the intended procedure to account for the resources used towards the intended procedure. Hospitals may want to review cancelled outpatient procedures to ensure proper reimbursement.

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