Local Coverage Article Billing and Coding

Billing and Coding: Screening Colonoscopy Converted to a Diagnostic and/or Therapeutic Colonoscopy

A55069

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Contractor Information

Article Information

General Information

Article ID
A55069
Article Title
Billing and Coding: Screening Colonoscopy Converted to a Diagnostic and/or Therapeutic Colonoscopy
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

Article Guidance

Article Text

If during a colonoscopy a pathology is encountered that necessitates an intervention which converts the screening colonoscopy to a diagnostic/therapeutic colonoscopy, the appropriate CPT® code which includes the –PT modifier for the diagnostic/therapeutic colonoscopy must be submitted with an appropriate diagnosis to justify the procedure such as Z80.0-Family history of malignant neoplasm of digestive organs.

1) Choose the correct CPT® code which describes the procedure that was attempted.

2) Append the –PT modifier to the CPT® code. The –PT modifier indicates a screening colonoscopy has been converted to a diagnostic test or other procedure.

3) Use an appropriate ICD-10 diagnosis code to indicate the procedure was a screening procedure. The diagnosis Z80.0- Family history of malignant neoplasm of digestive organs is an example of a diagnosis that can be used to indicate screening of beneficiaries at high risk.

Coding Information

CPT/HCPCS Codes

Group 1

(7 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
45380 COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE
45381 COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE
45382 COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD
45384 COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS
45385 COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE
G0105 COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK
G2204 PATIENTS BETWEEN 45 AND 85 YEARS OF AGE WHO RECEIVED A SCREENING COLONOSCOPY DURING THE PERFORMANCE PERIOD

CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
PT COLORECTAL CANCER SCREENING TEST; CONVERTED TO DIAGNOSTIC TEST OR OTHER PROCEDURE

ICD-10-CM Codes that Support Medical Necessity

Group 1

(2 Codes)
Group 1 Paragraph

Note: LCD L34454 and Article A56632 do not address criteria for the performance of or coding for screening procedures or screening procedures that are converted to diagnostic/therapeutic procedures based upon unanticipated pathology encountered during the visualization of the colon.

Group 1 Codes
CodeDescription
Z12.11 Encounter for screening for malignant neoplasm of colon
Z80.0 Family history of malignant neoplasm of digestive organs

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2023 R10

Under CPT/HCPCS Codes Group 1: Codes the description was revised for G2204. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/23.

06/30/2021 R9

Under ICD-10-CM Codes that Support Medical Necessity Group 1: Paragraph deleted the verbiage “Z80.0 does not appear as a covered ICD-10 code in the Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy A56632 article because the Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy L34454 LCD addresses ONLY procedures performed for diagnostic and/or therapeutic purposes.” Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes added Z12.11. This revision is retroactive effective for dates of service on or after 6/30/21.

04/07/2021 R8

Under CPT/HCPCS Codes Group 1: Codes added G0105. This revision is retroactive effective for dates of service on or after 4/7/21.

01/01/2021 R7

Under Article Text deleted CPT® code verbiage for 45380, 45381, 45382, 45384, and 45385. This revision is retroactive effective for dates of service on or after 1/1/2021.

Under CPT/HCPCS Codes Group 1: Codes added G2204. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

10/10/2019 R6

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual. Under Article Title changed the title from “Screening Colonoscopy Converted to a Diagnostic and/or Therapeutic Colonoscopy” to “Billing and Coding: Screening Colonoscopy Converted to a Diagnostic and/or Therapeutic Colonoscopy”. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy L34454 LCD and placed in this article. Under CPT/HCPCS Modifiers Group 1: Codes added modifier PT.

08/29/2019 R5

Under Covered ICD-10 Codes Group 1: Paragraph verbiage was changed to state “Note: Z80.0 does not appear as a covered ICD-10 code in the Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy A56632 article because the Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy L34454 LCD addresses ONLY procedures performed for diagnostic and/or therapeutic purposes. LCD L34454 and Article A56632 do not address criteria for the performance of or coding for screening procedures or screening procedures that are converted to diagnostic/therapeutic procedures based upon unanticipated pathology encountered during the visualization of the colon”. Formatting, punctuation and typographical errors were corrected throughout the article.

05/24/2018 R4

Under Article Text added the registered trademark symbol to each of the CPT codes listed in this section. Under Covered ICD-10 Codes parentheses were placed around the first “LCD” acronym, and the verbiage “Local Coverage Determination” was added in front of it.

02/26/2018 R3 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
01/29/2018 R2 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
06/22/2017 R1

Under Article Text verbiage changes (additions and deletions) were made in the first sentence and in statement #3 regarding the diagnosis Z80.0 (Family history of malignant neoplasm of digestive organs).

Associated Documents

Related Local Coverage Documents
LCDs
L34454 - Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
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Public Versions
Updated On Effective Dates Status
01/19/2023 01/01/2023 - N/A Currently in Effect You are here
06/23/2022 06/30/2021 - 12/31/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Screening Colonoscopy
  • Diagnostic Colonoscopy
  • Therapeutic Colonoscopy