Billing and Coding: Gastroenterology

Ensure you are getting reimbursed appropriately for your colonoscopy services by adhering to these documentation suggestions.

Document the location, every time. For a colonoscopy, make a note that you have advanced beyond the splenic flexure; otherwise, documentation will only support a sigmoidoscopy. If multiple biopsies, polypectomies or other procedures are performed in different sites of the intestine, note the location of each procedure, as these can be separately reported in some instances.

Don’t generalize. If you treat several lesions using different modalities, you may be eligible for additional reimbursement if you document the reason for changing methods. Document separately the number of lesions at each location treated with a single modality.

Keep count. Document the number of biopsies taken or polyps removed. Under certain circumstances, coders can bill using modifier 22 to report a services requiring an unusual amount of work and should be reimbursed at a higher level.

Watch your language. The words you choose can make a big difference in the codes that are reported. “Screening” colonoscopies are performed for early detection of colorectal cancer in patients who are not experiencing any symptoms. A “diagnostic” colonoscopy is performed on a patient who has symptoms. Even when defects are noted and treated during a screening colonoscopy, the screening is still defined as the purpose of the visit and would be the first-listed diagnosis on the claim form. For purposes of medical necessity, it’s critical to correctly note the purpose or intent of the visit in the patient’s record.

Know the patient demographic. If your patient qualifies for Medicare, your billers will report colonoscopy services using HCPCS Level II codes rather than CPT codes. The HCPCS codes differentiate between patients who are at risk and those who aren’t. To qualify as high risk, a patient must have a family history of colorectal cancer/polyps, or a personal history of colorectal cancer/polyps or other bowel disease. Patients at risk are eligible to have Medicare pay for a colonoscopy every two years; those not at risk are eligible only every 10 years. Careful documentation of the patient’s histories allows the coders to select the codes most appropriate for the service provided.

Rule out the rule outs. Keep in mind that once the service has been provided, the coder must be able to assign a diagnosis code. A “rule out” diagnosis will not suffice. If a test to rule out a condition has negative results, coders will look in the medical record for the symptoms that prompted the exam. Make sure you have documented all signs and symptoms.

Sheri Poe Bernard, CPC, CPC-H, CPC-P, is vice president of member relations at the American Academy of Professional Coders (AAPC), the nation’s largest education and credentialing association for medical coders. AAPC provides certified credentials to medical coders in physician offices, hospitals and outpatient centers. The three certifications AAPC offers are CPC, CPC-H and CPC-P and represent the gold standard certification for medical coding.