Medicare cut payments for screening colonoscopies by 5 percent in 2008 and will reduce payments by 7 percent this year. Follow these tips to maximize reimbursement.

It's not uncommon for a physician to find a polyp or perform a biopsy during a scheduled screening colonoscopy. This changes the coding of both the diagnosis and CPT codes for billing. The latest Medicare guidance is to bill the appropriate CPT codes for the procedure(s) performed (45385, for example), but not to bill the G-code for a screening procedure. On the claim listing of the diagnoses, sequence the screening V76.51 code first, followed by the 211.3 polyp or other appropriate diagnosis code(s). When linking the diagnosis to the procedure on the claim form, only link the 211.3 polyp or other pertinent code with the 45385 or other colonoscopy code; don't link the V76.51 screening code in field 24E to any procedure code billed unless otherwise directed by your Medicare carrier.

Use code 45378 for diagnostic colonoscopy procedures without a biopsy or removal of a polyp, for a screening colonoscopy for payors other than Medicare and for Medicare patients with symptoms for studies not being done as screening tests.

Your scheduler should find out from the physician's office if the colonoscopy is scheduled for symptoms or as a screening procedure. If a screening turns into a biopsy or polypectomy, both the coding and the patient's out-of-pocket owing portion will change. Verify insurance benefits for both screening and diagnostic/surgical colonoscopy procedures. Explain the benefits for both types of colonoscopies to the patient beforehand. It's a good idea to put the patient's financial responsibility information in writing and give him a copy before the procedure.

The key to accurately coding endoscopies is knowing exactly what the surgeon did and the final destination of the scope. For example, to qualify as a colonoscopy, the scope must move beyond the splenic flexure of the colon.

When billing for multiple endoscopies, check CCI unbundling and "separate procedure" status in the CPT book and sequence the codes on the claim form from highest to lowest payment weight. For definition purposes, "separate site" is a separation between lesions of at least 1 cm.

When the word "snare" appears in the OP report as the technique used to remove a polyp, use 45385 regardless of whether the OP report states a polyp was removed by "cold snare" or "hot snare" or whether the snare is monopolar or bipolar.

The control of bleeding is included in biopsy (and most other) endoscopic procedures, and isn't separately billable, unless the patient comes in for the procedure with a GI bleed. You can control bleeding through injections and cauterizations. Code injections of epinephrine through an endoscope as 43255, which all payors might not reimburse separately. The control of bleeding usually won't be reimbursed separately from the EGD procedure, unless the EGD is completed and the patient has a post-op bleed, necessitating a return to the OR for treatment.

For either a colonoscopy or EGD, if one lesion is biopsied and a separate lesion is removed during the same case, code both the biopsy of the lesion and the removal of the separate lesion. Append a ??"59 modifier to the biopsy procedure.

If a single lesion (or multiple biopsies from the same or different lesions) is biopsied but not excised, use the biopsy code; report this code once regardless of the number of biopsies taken. If a lesion is biopsied and then excised, code only for the excision. You can bill both the excision and biopsy codes if the biopsy is taken from a different lesion than was excised. If you're billing for the biopsy and excision, append the ??"59 modifier to the biopsy code.

Screening colonoscopies (G0105) for high-risk Medicare patients are covered once every 24 months. A high-risk patient has one or more of the following:

• personal history of colorectal cancer;
• personal history of adenomatous polyps;
• inflammatory bowel disease; or
• a close relative (sibling, parent or child) who has had colorectal cancer or adenomatous polyposis.

For Medicare patients not meeting criteria for high risk, use code G0121 for a screening colonoscopy, which are covered once every 10 years.

If a colonoscopy that begins as a diagnostic procedure turns into a therapeutic or surgical procedure through the same scope, include the diagnostic scope in the therapeutic procedure and don't bill for it separately. If the physician takes a biopsy from one site and then notes a suspicious lesion at a different site and does a polypectomy, append a ??"59 modifier to the 45380 biopsy code to avoid an unbundling denial.

If the physician attempts but fails to remove a polyp by one technique (snare, for example), but is successful at removing the polyp via another technique (such as hot biopsy forceps), only bill the CPT code for the procedure that was successful (45384).

Use CPT code 45378 for a diagnostic colonoscopy. There will be a symptom prompting the test and this is not a screening procedure for Medicare. Use this code for screening colonoscopies billed to payors other than Medicare.

If the patient has a particularly long GI tract, and the physician runs out of scope before viewing the entire colon — for example, the scope goes past the splenic flexure, but doesn't extend all the way to the cecum — these procedures should have a ??"52 modifier appended for billing purposes.

When a physician removes two (or more) separate lesions by two different methods in a colonoscopy, you may bill the code for each method (unless both procedures are performed on the same lesion). You may need to use the ??"59 modifier if the codes are unbundled in the CCI edits.

List the correct diagnosis codes. Diagnosis codes are the mechanism for providing payors with the "what" and "why" the service(s) was necessary and justify the medical necessity of the procedures you perform.

Be aware of Medicare LCD policies. Carefully follow Medicare Local Carrier Determination (LCD) policies that affect procedures you do for allowable diagnoses to ensure proper reimbursement. Not following Medicare's listing of covered diagnoses for EGDs and colonoscopy procedures in LCDs can result in a medical necessity denial.

Use the pathology report to code definitively. Don't code such diagnoses as rule-outs, suspected, vs. or probable. If you don't know whether the condition was ruled out, code using the symptoms for which the procedure was performed. In most cases, it's good practice to wait until the path report comes back before coding the claim, as the exact diagnosis is needed for correct coding of neoplasm conditions. However, it's not necessary to hold all colonoscopy claims for path reports. If the procedure report states the physician removed a colon polyp and doesn't indicate that he suspects a cancerous lesion (using such language as a "suspicious" polyp), code the 211.3 colon polyp diagnosis and bill the claim.

Sometimes, you have no alternative but to use an unlisted CPT procedure code when you can't find an exact code. Describe the service or procedure when you use an unlisted procedure code. Submit the claim with the OP report to justify the procedure performed and explain what was done. Be aware that Medicare doesn't reimburse ASCs for unlisted CPT codes.

A CPT code designated as a "separate procedure" in the CPT book is a component of a more complex service and is usually not identified or billed separately. When the procedure is performed alone, or not as part of a larger or more inclusive procedure, report "separate procedure" by itself or with the ??"59 modifier. The separate procedure designation indicates that the procedure may be:

• performed independently;
• a different site or organ system (such as an EGD and colonoscopy performed at the same session);
• a separate incision/excision; or
• a separate lesion.

Avoid unbundling, the unethical practice of breaking out each individual part of a procedure and billing for it separately, at all costs. Don't code the individual components or incidental services of a surgical package when the primary procedure code includes these components. To avoid unbundling, pay close attention to code selection by coding with the most accurate and complete code available, using CPT guidelines. Here's a good rule-of-thumb: Whenever you bill more than one procedure code on one date of service, check each code in the Correct Coding Initiative (CCI) Unbundling material to see if any of the codes are unbundled. When GI procedures are unbundled, you might be able to bill the procedure when it was performed on a different lesion/separate site as long as it is 1 cm away from the other lesion.

The "global period" for most GI procedures is zero days. For ASCs performing procedures that have a global period for the physician, the ASC's global period is considered to be 24 hours.

When you have to stop a GI procedure because of scope problems, a poor prep, irregular patient anatomy or you encounter a tumor, append either a ??"52 reduced procedure or ??"73/??"74 discontinued procedure modifier to the CPT code for the procedure that was terminated. The choice of modifier would depend on the preference of the payor to which the claim is being submitted.

Medicare's definition of "anesthesia" for use of the ??"73 or ??"74 modifiers for terminated procedures is whatever the anesthesia for the case is, including conscious sedation. It doesn't have to be general anesthesia.

Avoid canned OP reports. Medicare and other payors frown on the use of canned OP reports to document procedures. If the physician uses a template, the OP reports must still be tailored to each patient's procedure, and must not appear to be canned. Medicare refers to these as "cloned" records, which can be a compliance issue and malpractice issue for both the surgical center and the physician.