Saturday, July 10, 2021

Venipuncture CPT codes - 36415, 36416, G0471

 

CPT Code and Definitions


36415 Collection of venous blood by venipuncture


36416 Collection of capillary blood specimen (e.g., finger, heel, ear stick)


G0471 Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a SNF or by a laboratory on behalf of a HHA 


S9529 Routine venipuncture for collection of specimen (s), single home bound, nursing home, or skilled nursing facility patient.



Venipuncture Definition

Venipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing. There are several different methods for the collection of a blood sample. The most common method and site of venipuncture is the insertion of a needle into the Cubital vein of the anterior forearm at the elbow fold.



Reimbursement Guidelines


A. For Professional and Clinical Laboratory Services (including Dialysis Centers and Home Health): 

Venipuncture is the most common method used to obtain blood samples for blood or serum lab procedures. The work of obtaining the specimen sample is an essential part of performing the test.


Reimbursement for the venipuncture is included in the reimbursement for the lab test procedure code.

1. CPT Code 36415

a. For Moda Health Advantage:

36415 is eligible for separate reimbursement, consistent with Original Medicare payment policy.

b. For all other lines of business, the following policies apply:


i. CPT 36415 is only eligible to be billed once, even when multiple specimens are drawn or when multiple sites are accessed to obtain an adequate specimen size for the

desired test(s). (CMS4)


ii. Moda Health does not allow separate reimbursement for CPT 36415 (venipuncture) when billed in conjunction with a blood or serum lab procedure performed on the

same day and billed by the same provider (procedure codes in the 80048 - 89399 range). 36415 will be denied as a subset to the lab test procedure. 


iii. If some of the blood and/or serum lab procedures are performed by the provider and others are sent to an outside lab, CPT 36415 is not eligible for separate reimbursement. 


iv. Modifier 90 (reference laboratory) will not bypass the subset edit. The outside laboratory that is actually performing the test will need to bill Moda Health directly for the lab tests in order for 36415 to be separately reimbursable to the provider performing the venipuncture to obtain the specimen for the outside laboratory.


v. The use of modifiers XS, XP, XE, XU, or 59 with 36415 when blood/serum lab tests are also billed is not a valid use of the modifier. The venipuncture is not a separate procedure in this situation.


vi. Moda Health does allow separate reimbursement for CPT 36415 when the only other lab services billed for that date by that provider are for specimens not obtained by venipuncture (e.g. urinalysis). 


* For Ambulatory Surgery Centers (ASC):

Per CMS policy, routine venipuncture or other routine collection of specimens, if needed, is not separately reimbursable to ASCs. These services are included in the packaged reimbursement for the primary procedure or service.


*For Outpatient Hospital (OPPS) Services:

The CMS OPPS Medically Unlikely Edit (MUE) limits apply for routine venipuncture procedure codes or other routine collection of specimens.


Coding Guidelines for CPT 36415


• When existing vascular access lines or selectively placed catheters are utilized to procure arterial or venous samples, reporting the sample collection separately is inappropriate. (CMS3)


• CPT codes 36500 or 75893 may occasionally be appropriate if more extensive work beyond routine venipuncture is required. For instance, if a physician needs to place a catheter to obtain a blood specimen from a specific organ or location. CPT codes 36500 (venous catheterization for selective organ blood sampling) or 75893 (venous sampling through catheter with or without angiography...) may be reported for venous blood sampling through a catheter placed for the sole purpose of venous blood sampling. CPT code 75893 includes concomitant venography if performed.(CMS3) 


Background Information


Venipuncture or phlebotomy is the puncture of a vein with a needle or an IV catheter to withdraw blood. Venipuncture is the most common method used to obtain blood samples for blood or serum lab procedures, and is sometimes referred to as a “blood draw.” Collection of a capillary blood specimen (36416) or of venous blood from an existing access line or by venipuncture that does not require a physician’s skill or a cutdown is considered “routine venipuncture.”



Overview


This policy addresses the ConnectiCare, Inc. reimbursement policies pertaining to clinical laboratory and related laboratory services (e.g., venipuncture and the handling and conveyance of the specimen to the laboratory) for provider claims submitted on a CMS-1500, whether performed in a physician’s office, a hospital laboratory, or an independent laboratory. Note this policy does not address reimbursement for all laboratory codes. Coding relationships for laboratory topics not included within this policy are administered through ConnectiCare administrative and reimbursement policies. All services described in this policy may be subject to additional reimbursement policies.



If you are a physician, practitioner, or medical group, you may only bill for services that you or your staff perform. Pass-through billing is not permitted and may not be billed to our members. We only reimburse for laboratory services that you are certified to perform through the Federal Clinical Laboratory Improvement Amendments (CLIA). You must not bill our members for any laboratory services for which you lack the applicable CLIA certification. To validate whether a test requires CLIA visit CMS/FDA websites.


Policy statement:


Duplicate Laboratory Charges – Multiple Providers


Only one provider will be reimbursed when multiple providers bill identical services. ConnectiCare will reimburse the provider or entity that actually performed the test. Duplicate laboratory services are defined as identical or equivalent bundled laboratory codes. Note: For the purpose of this policy, CPT codes 82947 and 82948 are not considered to be equivalent codes:

• 82947 - Glucose; quantitative, blood (except reagent strip)

• 82948 - Glucose; blood, reagent strip

Pathologist and Physician Laboratory Providers

If a pathologist and another physician or other qualified health care professional’s offices submit identical laboratory codes for the same patient on the same date of service, only the pathologist’s service is reimbursable.


Place of Service


The Place of Service (POS) identifies where the laboratory service was performed. ConnectiCare uses the codes indicated in the Centers for Medicare and Medicaid Services (CMS) Place of Service Codes for Professional Claims Database to determine if laboratory services are reimbursable.


Examples:

• If the physician bills for lab services performed in his/her office, the POS code 11 for "Office" is reported.

• If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, the POS code 81 for "Independent Laboratory" is reported. Laboratory Panels


Individual laboratory codes, which together make up a laboratory panel code, will be combined into and reimbursed as the more comprehensive laboratory panel code as described under the specific laboratory panel headings below.


ConnectiCare also considers an individual component code included in the more comprehensive panel code when reported on the same date of service by the same individual physician or other qualified health care professional. The Professional Edition of the CPT book, Organ or DiseaseOriented Panel section states: "Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes."


In addition, it is not appropriate for a laboratory panel to be split amongst multiple laboratories or office/laboratory settings. This is also considered unbundling of a laboratory panel. Laboratory panels that have been split billed, or unbundled are not reimbursable. Venipuncture and Specimen Collection Specimen collection fees are not reimbursed when billed by the same provider who is rendering blood or related laboratory services Consistent with CMS, only one collection fee for each type of specimen per patient encounter, regardless of the number of specimens drawn, will be allowed. A collection fee will not be reimbursed to anyone who did not extract the specimen.


Venous blood collection by venipuncture and capillary blood specimen collection (CPT codes 36415 and 36416) will be reimbursed once per patient per date of service when reported by the Same Individual Physician or Other Qualified Health Care Professional. When CPT code 36416 is submitted with CPT code 36415, CPT code 36415 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36416 from bundling into CPT code 36415.


Consistent with CMS, ConnectiCare considers collection of a specimen from a completely implantable venous access device and from an established catheter (CPT codes 36591 and 36592) to be bundled into services assigned a CMS NPFS Status Indicator of A, R or T provided on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional, for which payment is made. When CPT code 36591 is submitted with CPT code 36592, CPT code 36592 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36591 from bundling into CPT code 36592.


ConnectiCare considers venipuncture code S9529 (Routine venipuncture for collection of Specimen(s), single homebound, nursing home, or skilled nursing facility patient) a nonreimbursable service. The description for S9529 focuses on place of service for a service that is more precisely represented by CPT code 36415 and reported with the appropriate CMS place of service code.


Consistent with CMS, specimen collection HCPCS code G0471 is reimbursable only when a Specimen is collected from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency.


Laboratory Handling Laboratory handling and conveyance CPT codes 99000 and 99001 and HCPCS code H0048 are included in the overall management of a patient and are not separately reimbursed when submitted with another code, or when submitted as the only code on a claim for the same date of service.


Code Q0091


HCPCS code Q0091 (screening Papanicolaou smear, obtaining, preparing, and conveyance of cervical or vaginal smear to laboratory) is eligible for reimbursement for Medicare beneficiaries only. For all other products it is considered to be part of the E/M and Pap smear codes and is not eligible for separate reimbursement.

Guidelines for Billing Units When submitting multiple units of one code, the guidelines are based on code descriptions:


• If the CPT or HCPCS code description contains "per" or "each" or another unit of measurement and multiple services are provided, providers should bill the code on one line with the appropriate number of units.


• If the code does not contain a measurement such as "per" or "each" in the description of the code, providers should report one unit for all services.


Venipuncture and Specimen Collection


Consistent with CMS, only one collection fee for each type of Specimen per patient encounter, regardless of the number of Specimens drawn, will be allowed. A collection fee will not be reimbursed to anyone who did not extract the Specimen. Venous blood collection by venipuncture and capillary blood Specimen collection (CPT codes 36415 and 36416) will be reimbursed once per patient per date of service when reported by the Same Individual Physician or Other Qualified Health Care Professional. When CPT code 36416 is submitted with CPT code 36415, CPT code 36415 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36416 from bundling into CPT code 36415.


Consistent with CMS, UnitedHealthcare considers collection of a Specimen from a completely implantable venous access device and from an established catheter (CPT codes 36591 and 36592) to be bundled into services assigned a CMS NPFS Status Indicator of A, R or T provided on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional, for which payment is made. When CPT code 36591 is submitted with CPT code 36592, CPT code 36592 is the only venipuncture code considered eligible for reimbursement. No modifier overrides will exempt CPT code 36591 from bundling into CPT code 36592.


UnitedHealthcare considers venipuncture code S9529 a non-reimbursable service. The description for S9529 focuses on place of service for a service that is more precisely represented by CPT code 36415 and reported with the appropriate CMS place of service code.

Consistent with CMS, specimen collection HCPCS code G0471 is reimbursable only when a Specimen is collected from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency.


Venipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing. There are several different methods for the collection of a blood sample. The most common method and site of venipuncture is the insertion of a needle into the cubital vein of the anterior forearm at the elbow fold. Please

refer to the coding section of this policy for the CPT code most applicable to the method of blood withdrawal.


This policy addresses the Health Plan’s reimbursement policies pertaining to clinical laboratory and related laboratory services (e.g., venipuncture and the handling and conveyance of the specimen to the laboratory) for provider claims submitted on a CMS-1500, whether performed in a physician’s office, a hospital laboratory,

or an independent laboratory. 


. Routine Venipuncture and the Collection of Blood Specimen 


A. Routine Venipuncture/Capillary Blood Collection


 Healthcare Common Procedure Coding System (HCPCS Level II) code S9529 and capillary blood collection code 36416, are eligible for separate reimbursement when reported with an E/M and/or a laboratory service. Unless an additional routine venipuncture/capillary blood collection is clinically necessary, the frequency limit for any of these services is once per member, per provider, per date of service. The frequency limit will also apply to any combination of these codes reported on the same date of service for the same member by the same provider. (See also our Frequency Editing Reimbursement Policy.)


When routine venipuncture CPT code 36415 is reported with Evaluation and Management (E/M) office visit codes (99201-99205 and 99211-99215) then the routine venipuncture code is included in the reimbursement for office visit E/M services and not reimbursed separately.


Modifiers will not override the edit.


Routine venipuncture CPT 36415 is eligible for separate reimbursement when reported with a laboratory service.


In addition, HCPCS code G0471 for the collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency (HHA) collected by a laboratory technician that is employed by the laboratory that is performing the test will be eligible for separate reimbursement when reported with a laboratory service.


B. Collection of Blood Specimen from Access Device or Catheter

 The Health Plan follows CPT coding guidelines which state that CPT codes 36591and 36592 should not be reported “…in conjunction with other services except a laboratory service.2 ” Therefore, CPT codes 36591 and 36592 are only eligible for separate reimbursement when reported with a laboratory service. See also our Bundled Services and Supplies Reimbursement Policy. 



Coding

The following tables are provided as an informational tools only to help identify some of the procedures described above. The inclusion or exclusion of a specific code does not indicate eligibility for reimbursement under all circumstances.

According to Health Plan policy, the following codes are eligible for separate reimbursement when reported with a laboratory service:


Code Description



36415 Collection of venous blood by venipuncture

36420 Venipuncture, cutdown; younger than age 1 year


Coding Tips

Local anesthesia is included in these services. For handling or conveyance of a specimen transported to an outside laboratory, see 99000. For venipuncture on a patient younger than 3 years of age, see 36400–36406. For venipuncture requiring physician skill on a patient 3 years of age or older, see code 36410. Do not report code 36420 if providedwith critical care; see codes 99468–99480. Code 36425 should not be reportedwith endovenous ablation(36475–36479)


Terms To Know

critical care. Treatment of critically ill patients in a variety of medical emergencies that requires the constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, respiratory failure, postoperative complications, critically ill neonate). cutdown. Small, incised opening in the skin to expose a blood vessel, especially over a vein (venous cutdown) to allow venipuncture and permit a needle or cannula to be inserted for the withdrawal of blood or administration of fluids.


venipuncture. Piercing a vein through the skin by a needle and syringe or sharp-ended cannula or catheter to draw blood, start an intravenous infusion, instill medication, or inject another substance such as radiopaque dye


Venipuncture is the process of collecting or “drawing” blood from a vein and the most common way to collect blood specimens for laboratory testing. It is the most frequent procedure performed by a phlebotomist and the most important step in this procedure is patient identification. This chapter addresses how to correctly identify all types of patients and how to safely obtain high-quality blood specimens from them. Venipuncture techniques covered in this chapter include ETS, butterfly, and syringe procedures on arm and hand veins. This chapter also addresses challenges and unique issues associated with pediatric, geriatric, dialysis, long-term care, home care, and hospice patients. Venipuncture procedures in this chapter conform to CLSI standards.



Cognitively Impaired or Combative Patients Some patients may display unpredictable or sudden movements and behaviors that could pose a danger to themselves, the phlebotomist or others nearby. If a patient exhibits such behaviors it is essential for an additional person or employee to be enlisted to assist if necessary. In addition, make certain you have an obstructed exit route in case it is needed. Also be mindful of where you place equipment, being certain to keep it out of the reach of the patient. As with venipuncture on every patient, always have a gauze pad ready and be prepared to release the tourniquet quickly in case the patient pulls the needle out, or suddenly jerks causing the needle to either come out or go deep into the arm. Should the needle penetrate deep into the arm the patient’s nurse or healthcare provider must be informed and the incident documented according to facility policy.


Sunday, May 30, 2021

CPT 80053, Comprehensive metabolic panel

 

CODE DESCRIPTION


80053 Comprehensive metabolic panel This panel must include the following: Albumin (82040), Bilirubin, total (82247), Calcium, total (82310), Carbon dioxide

(bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total (84155), Sodium (84295), Transferase, alanine amino (ALT) (SGPT) (84460), Transferase, aspartate amino (AST) (SGOT) (84450), Urea Nitrogen (BUN) (84520)



Organ or Disease-Oriented Laboratory Panel Codes


The Organ or Disease-Oriented Panels as defined in the CPT book are codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076, and 80081. According to the CPT book, these panels were developed for coding purposes only and are not to be interpreted as clinical parameters. UnitedHealthcare uses CPT coding guidelines to define the components of each panel.


UnitedHealthcare also considers an individual component code included in the more comprehensive Panel Code when reported on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional. The Professional Edition of the CPT ® book, Organ or Disease-Oriented Panel section states: "Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes."


For reimbursement purposes, UnitedHealthcare differs from the CPT book's inclusion of the specific number of Component Codes within an Organ or Disease-Oriented Panel. UnitedHealthcare will bundle the individual Component Codes into the more comprehensive Panel Code when the combined reimbursement for the individual Panel Code(s) exceeds the reimbursement amount of the Panel Code or when the designated number of Component Codes identified within a Panel Code are submitted as set forth more fully in the tables below. The tables for CPT codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076 and 80081 identify the Component Codes that UnitedHealthcare will rebundle into the specific panel.



CPT coding guidelines indicate that Panel CPT code 80047 should not be reported in conjunction with CPT code 80053. If a submission includes CPT 80047 and CPT 80053, only CPT 80053 will be reimbursed.


CPT coding guidelines indicate that, Panel CPT code 80048 should not be reported in conjunction with Panel CPT 80053. If a submission includes Panel CPT 80048 and 80053, only Panel CPT 80053 will be reimbursed. There are 2 configurations for, Panel CPT code 80048:

1. A submission that includes 5 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80048.


Panel Code: 80048

Must contain 5 or more of the following Component Codes for the same patient on the same date of service

82310 82374 82435 82565 82947

84132 84295 84520


A submission that includes, Panel CPT code 80053, Panel CPT code 84443 and one of the following Component Codes, either CPT codes 85025 or 85027 + 85004 or 85027 + 85007 or 85027 + 85009 by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service, Panel CPT code 80050.


Panel Code: 80050


Includes the following Panel Code: 80053 

Plus the following Component Code: 84443 

Plus 1 of the following CBC or combination of CBC Component Codes for the same patient on the same date of service: :

85025 85027 + 85027 + 85027 +

85004 85007 85009


When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.


When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.

Panel code 80053, a component of Panel code 80050, includes all components of Panel CPT code 80076 except for code 82248.


Panel, 80053


There are 3 configurations for Panel CPT code 80053:

1. A submission that includes 10 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.

Panel Code: 80053

Must contain 10 or more of the following Component Codes for the same patient on the same date of service:

82040 82247 82310 82374 82435

82565 82947 84075 84132 84155

84295 84450 84460 84520


2. A submission that includes a Panel CPT code 80048, and 2 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.


Panel Code: 80053

Includes the following Panel Code: 80048  Plus 2 or more of the following Component Codes for the same patient on the same date of service:

82040 82247 84075 84155 84450

84460


3. A submission that includes, Panel CPT code 80051, and 6 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as Panel CPT code 80053.

Panel Code: 80053

Includes the following Panel Code: 80051 Plus 6 or more of the following Component Codes for the same patient on the same date of service:

82040 82247 82310 82565 82947

84075 84155 84450 84460 84520


When the Same Individual Physician or Other Qualified Health Care Professional reports the Panel CPT codes 80053 with 80048 or 80076 for the same patient on the same date of service, neither Panel CPT codes 80048 nor 80076 will be reimbursed separately.

CPT Panel Code 80053 includes all of the components of CPT Panel Code 80048 and all the components of CPT Panel Code 80076, except for CPT 82248. Therefore, when performed with all of the components of Panel CPT code 80053, report CPT 82248 separately.


Coding Tip


This panel must include the following: Calcium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520). Code 80048 cannot be reported in conjunction with 80053.



80053 Comprehensive metabolic panel A comprehensive metabolic panel includes the following tests: albumin (82040), total bilirubin (82247), calcium (82310), carbon dioxide (bicarbonate) (82374), chloride (83435), creatinine (82565), glucose (82947), alkaline phosphatase (84075), potassium (84132), total protein (84155),

sodium (84295), alanine amino transferase (ALT) (SGPT) (84460), aspartate amino transferase (AST) (SGOT) (84450), and urea nitrogen (BUN) (84520). Blood specimen is obtained by venipuncture. See the specific codes for additional information about the listed tests



Code 80053 can not be used in addition to CPT codes 80048 and 80076.



This test may be performed using a CLIA-waived test system. Laboratories with a CLIA-waived certificate must report this code with modifier QW CLIA waived

test. See appendix 1 for CLIA-waived kits and test systems. Medicare covers colorectal screening for

* Indicates a mutually exclusive edit


80053 80048, 80051, 80069, 80076, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84450, 84460, 84520



 

Reimbursement is provided for tests that are performed in a panel if they are reasonable, medically necessary under the applicable medical policy, and otherwise reimbursable under the terms of the member's plan. The plan reserves the right to rebundle individual codes that belong to a panel. If a claim is submitted with individual codes that belong to a panel, our claim reviewers and/or correct coding software logic may rebundle the procedure codes for appropriate reimbursement. If the medical documentation submitted with a claim shows that a panel was ordered and performed but the claim submitted shows the individual components of the panel, claim reviewers may rebundle the codes into the appropriate panel for reimbursement. CPT states the following:


• Tests performed in addition to those specifically indicated for a particular panel should be reported separately from the panel code

Example, If the Electrolyte panel (80051) is billed, individual tests such as 82947 (Assay Glucose Blood Quant), 84520 (Assay of Urea Nitrogen), 82565 (Assay of

Creatinine) and 82550 (Assay of CK (CPK)) should be billed separately from the panel.


• Do not report two or more panel codes that include the same constituent tests performed from the same patient collection

Example, If the Comprehensive Metabolic Panel (80053) is billed, the Basic Metabolic Panel (80047) cannot be billed.


• If a group of tests overlaps two or more panels, you must use the panel that incorporates the greatest number of tests and report the remaining individual tests

Example, if 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium), 84295 (Assay of Serum Sodium), 84520 (Assay of

Urea Nitrogen), and 82947 (Assay Glucose Blood Quant) are billed, two panel codes overlap. The Basic Metabolic Panel (80047) and the Electrolyte Panel (80051) include

codes 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium) and 84295 (Assay of Serum Sodium). The Electrolyte Panel should be billed.


• The panel code should be billed when all individual tests in the panel have been performed and should not be billed separately

Example, If the Lipid Panel (80061) is billed, then procedures 82465 (Assay BLD/Serum Cholesterol), 83718 (Assay of Lipoprotein) and 84478 (Assay of Triglycerides) should have been performed. 


80053 Comprehensive Metabolic Panel

82040 Assay of Serum Albumin

82247 Bilirubin Total

82310 Assay of Calcium

82374 Assay Blood Carbon Dioxide

82435 Assay of Blood Chloride

82565 Assay of Creatinine

82947 Assay Glucose Blood Quant

84075 Assay Alkaline Phosphatase

84132 Assay of Serum Potassium

84155 Assay of Protein Serum

84295 Assay of Serum Sodium

84460 Alanine Amino (ALT) (SGPT)

84450 Transferase (AST) (SGOT)

84520 Assay of Urea Nitrogen



Purpose of Policy


This policy is intended to help clarify how and why the same test or service may process differently depending upon the primary diagnosis code with which it is billed. The focus of this policy is on the differences between the Preventive and the Medical benefit categories.



Scope


This policy applies to all Commercial medical plans.


Reimbursement Guidelines


A. Categories of diagnostic tests covered and not covered as routine/preventive


1. Moda Health covers the preventive services mandated in the Patient Protection and Affordable Care Act (PPACA) at 100% (no cost-sharing responsibility to the member), when the member is seeing an in-network provider.


2. In addition to the mandated PPACA preventive services, Moda Health also covers a limited list of additional tests when billed with a routine, preventive, or screening diagnosis code.


The codes and tests eligible for this additional screening coverage are determined by a Moda Health Medical Director and are listed below. NOTE: These tests are not eligible for the 100%, no-cost-share Affordable Care Act preventive benefit because they are not on the PPACA list of mandated preventive services.

The tests will be covered (rather than denied), but all of the following tests are subject to the member’s usual cost-sharing and deductible requirements, even

when billed with a preventive diagnosis.


Lab Panels


Organ- or disease-oriented lab panels were developed to allow for coding of a group of tests. Providers are expected to bill the lab panel when all the tests listed within each panel are performed on the same date of service. When one or more of the tests within the panel are not performed on the same date of service,

providers may bill each test individually. Providers may not bill for a panel and all the individual tests listed within that panel on the same day. However, other tests performed in addition to those listed on the panel on the same date of service may be reported separately, in addition to the panel code. Providers must

follow CPT coding guidelines when reporting multiple panels. For example, providers cannot report basic panel code 80048 with comprehensive panel code 80053 on the same date of service, because all the lab tests in 80048 are components of 80053.



On May 3, 2019 CMS issued Change Request 11248, which re-implements the Automated Multi-Channel Chemistry (AMCC) Lab Panel Claims Payment System Logic. This logic was introduced in 2017 but was suspended beginning CY 2018, due to the Protecting Access to Medicare Act of 2014 (PAMA). PAMA required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the Clinical Laboratory Fee Schedule (CLFS). Under PAMA, reporting entities must report to CMS certain private payer rate information for their component applicable laboratories. The implementation of PAMA required Medicare to pay the weighted median of private payor rates for each separate HCPCS code, as one National fee schedule rate rather than individual rates per state.


Prior to PAMA, CMS paid for certain chemistry tests using Automated Test Panels (ATPs). ATPs used claims processing logic to apply a bundled rate to sets of these codes based off how many ATPs were ordered. The claims processing system would not pay more for all ATPs than the associated CPT Panel (80047-80081). Any duplicated chemistry tests across ATPs or separately billed without a 91 modifier are not counted in the ATP test total. Below will further illustrate the logic and the effect on reimbursement. The Ohio rate of the 2017 CLFS is used for this demonstration, as the 2019 CLFS has not been updated with ATP entries as of the time of this article.


Example


A lab receives an order for a Comprehensive Metabolic Panel (80053) and a Lipid Panel (80061). Both panels are processed, results sent to the referring provider and a claim is sent to Medicare for HCPCS 80053 and 80061. The 2017 CLFS indicates payment for each HCPCS code as:

80053 $14.49

80061 $17.45

Total $31.94


Under the ATP payment methodology, payment will be determined based off the total number of unique chemistry tests performed.

Medicare will first strip each panel into its component codes as follows:


80053 HCPCS 80061 HCPCS

82040 82465

82247 83718

82310 84478

82374

82435

82565

82947

84075

84132

84155

84295

84460

84450

84520


Thursday, May 20, 2021

CPT 71275 AND 74174

 CPT Code    Description

71275       Computed tomographic angiography, chest (non-coronary), with contrast material(s), including noncontrast images, if performed, and image post-processing 


CPT Code Acceptable S/S Procedure to Pre-Cert

71275 * Thoracic Aortic Dissection

* Thoracic Aortic Aneurysm

* Coarctation

* Aortic Root Dilation CTA Chest


74174 * Abdominal Aortic Dissection

* Mesenteric Ischemia

* Bowel Ischemia

* Stent Obstruction CTA Abdomen and Pelvis

* Thoracic Abdominal Aortic Dissection requires both codes 71275 and 74174


CPT Codes: 71275

Computed tomography angiography (CTA) is a non-invasive imaging modality that may be used in the evaluation of thoracic vascular problems. Chest CTA (non-coronary) may be used to evaluate vascular conditions, e.g., pulmonary embolism, thoracic aneurysm, thoracic aortic dissection, aortic coarctation, or pulmonary vascular stenosis. CTA depicts the vascular structures as well as the surrounding anatomical structures.

Initial Clinical Reviewers (ICRs) and Physician Clinical Reviewers (PCRs) must be able to apply criteria based on individual needs and based on an assessment of the local delivery system.


INDICATIONS FOR CHEST CTA:


For evaluation of suspected or known pulmonary embolism (excludes low risk*)

For evaluation of suspected or known vascular abnormalities:

* For evaluation of a thoracic/thoracoabdominal aneurysm or dissection (documentation of clinical history may include hypertension and reported “tearing or ripping type” chest pain.

* Congenital thoracic vascular anomaly, (e.g., coarctation of the aorta or evaluation of a vascular ring suggested by GI study).

* Signs or symptoms of vascular insufficiency of the neck or arms (e.g., subclavian steal syndrome with abnormal ultrasound).

* Follow-up evaluation of progressive vascular disease when new signs or symptoms are present.

* Primary or secondary pulmonary hypertension.


Preoperative evaluation

* Known or suspected vascular abnormalities seen on prior imaging

* Ablation procedure for atrial fibrillation.


Postoperative or post-procedural evaluation

* Physical evidence of post-operative bleeding complication or re-stenosis.

* Post-surgical follow up when records document medical reason requiring additional imaging


Chest CTA and Abdomen CTA or Abdomen/Pelvis CTA or Pelvis CTA combo:

* For evaluation of extensive vascular disease involving the chest and abdominal cavities such as aortic dissection, vasculitic diseases such as Takayasu’s arteritis, significant post-traumatic or postprocedural vascular complications, etc.

* For preoperative or preprocedural evaluation such as transcatheter aortic valve replacement (TAVR).


ADDITIONAL INFORMATION RELATED TO CHEST CTA:

CTA and Coarctation of the Aorta – Coarctation of the aorta is a common vascular anomaly characterized by a constriction of the lumen of the aorta distal to the origin of the left subclavian artery near the insertion of the ligamentum arteriosum. The clinical sign of coarctation of the aorta is a disparity in the pulsations and blood pressures in the legs and arms. Chest CTA may be used to evaluate either suspected or known aortic coarctation and patients with significant coarctation should be treated surgically or interventionally.

CTA and Pulmonary Embolism (PE) – Note: D-Dimer blood test in patients at low risk* for DVT is indicated prior to CTA imaging. Negative D-Dimer suggests alternative diagnosis in these patients. *Low risk defined as NO to ALL of the following questions:

1) Evidence of current or prior DVT;

2) HR > 100;

3) Cancer diagnosis;

4) Recent surgery or prolonged immobilization;

5) Hemoptysis;

6) History of PE; and another diagnosis is more likely.

CTA has high sensitivity and specificity and is the primary imaging modality to evaluate patients suspected of having acute pulmonary embolism. When high suspicion of pulmonary embolism on clinical assessment is combined with a positive CTA, there is a strong indication of pulmonary embolism. Likewise, a low clinical suspicion and a negative CTA can be used to rule out pulmonary embolism. CTA and Thoracic Aortic Aneurysms – Computed tomographic angiography (CTA) allows the examination of the precise 3-D anatomy of the aneurysm from all angles and shows its relationship to branch vessels. This information is very important in determining the treatment: endovascular stent grafting or open surgical repair.


CTA and Thoracic Aorta Endovascular Stent-Grafts – CTA is an effective alternative to conventional angiography for postoperative follow-up of aortic stent grafts. It is used to review complications after thoracic endovascular aortic repair. CTA can detect luminal and extraluminal changes to the thoracic aortic after stent-grafting and can be performed efficiently with fast scanning speed and high spatial and temporal resolution.


Chest CT

1. Intrathoracic abnormalities found on chest x-ray, fluoroscopy, abdominal CT scan, or other imaging modalities may be further evaluated with chest CT with contrast (CPT® 71260).

a. “Abnormalities” through these guidelines may include suspected lung or pleural nodules or masses, pleural effusion, adenopathy or other findings that are not considered benign. 

b. Lung nodule(s) identified incidentally on:

i. Chest CTA without and with contrast (CPT® 71275), or

ii. Chest MRI without contrast (CPT® 71550), or

iii. Chest MRI without and with contrast (CPT® 71552), or

iv. Chest MRA without and with contrast (CPT® 71555) can replaceChest CT with contrast (CPT® 71260) or chest CT without contrast (CPT® 71250) as the initial dedicated study

2. Chest CT without contrast (CPT® 71250) can be used for the following:

a. Patient has contraindication to contrast.

b. Follow-up of pulmonary nodule(s).

c. High Resolution CT (HRCT).

d. Low-dose chest CT (CPT® G0297)

3. Chest CT without and with contrast (CPT® 71270) does not add significant diagnostic information above and beyond that provided by chest CT with contrast, unless a question regarding calcification, most often within a lung nodule, needs to be resolved.

4. High resolution chest CT should be reported only with an appropriate code from the set CPT® 71250-CPT® 71270.

a. No additional CPT® codes should be reported for the “high resolution” portion of the scan. The “high resolution” involves additional slices which are not separately billable.

E. Chest CTA (CPT® 71275)

1. Chest CTA (CPT® 71275) can be considered for suspected Pulmonary Embolism and Thoracic Aortic disease.

a. CTA prior to minimally invasive or robotic surgery 


Non-Cardiac Chest Pain Imaging

1. Initial evaluation should include a chest x-ray.1,2

a. If x-ray is abnormal, chest CT with contrast (CPT® 71260) or CTA chest with contrast (CPT® 71275) can be performed.1,2,3,4



 Hemoptysis

A. Chest CT with contrast (CPT® 71260) OR without contrast (CPT® 71250) OR CTA chest (CPT® 71275) may be performed after:

1. Abnormal chest x-ray, or

2. No chest x-ray needed if any of the following:

a. High risk for malignancy with >40 years of age and >30 pack-year smoking history, or

b. Persistent/recurrent with >40 years of age or >30 pack year smoking history, or

c. Massive hemoptysis (=30 cc per episode or unable protect airway).1


Thursday, May 6, 2021

CPT CODE 97597, 97598 - Debridement procedure

CPT CODE AND Description 


CPT code 97598 (Debridement [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof) was identified by the RUC on a list of services that were originally surveyed by one specialty but are now typically performed by a different specialty.


CPT code 97597 (Debridement [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less) was included for review as part of the family despite being reviewed at the October 2018 RUC meeting.


Billing Guidelines


Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.

2. Typically bill CPT 97597 and/or CPT 97598 for recurrent wound debridements when medically reasonable and necessary.

3. CPT 97597 and/or CPT 97598 are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.

4. CPT code 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). Secretions of any consistency do not meet this definition. The mere removal of secretions (cleansing of a wound) does not represent a debridement service.

5. The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.

6. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.

7. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.

8. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.

9. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their Plan of Care. If it is a physician or nonphysician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies

Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse

practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements.

10. CPT code 97602 has been assigned a status indicator "B" in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare.

11. Documentation must support the HCPCS being billed.

12. Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598). Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.

13. Infrared (97026), ultra-sound thermal (97035), phototherapy-ultraviolet (97028) modalities are not payable per the LCD.


Coding Guidelines


1. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047. Wound debridements (11042-11047) are reported by depth of tissue that is removed and by surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. See CPT coding guidance for proper use of the coding.

2. Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.

3. CPT code 11043, 11046 and 11044, 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).

4. CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and bone.



• 97597 Removal of devitalized tissue from wounds, selective debridement, without anesthesia, wound assessment, topical applications, instructions for ongoing care, total wound surface area first 20 sq cm . May include scalpel, scissors, waterjet


• CPT 15002-15005 are NOT to be used for the removal of nonviable tissue/debris in chronic wounds left to heal by secondary intention. CPT 11042-11047 and CPT 97597- 97598 are to be used for this.


CPT codes 97597 and 97598,

• “to remove devitalized and/or necrotic tissue and promote healing”

• 97597 Selective debridement, without anesthesia – wound area <20 sq cm

• High pressure water jet

• Sharp selective debridement (scissors, scalpel and forceps)

• 97598 Wound area > 20 sq cm


Multiple Levels of Debridement Coding Example:

The patient has five wounds. There is a superficial blister on the right 1st MTPJ, an ulceration that penetrates to subcutaneous tissue beneath the left second metatarsal head, an ulceration that penetrates to subcutaneous tissue on the right anterior leg, an ulceration with necrotic Achilles tendon exposed on the

posterior right heel, and a lateral left fibular malleolus with bone exposed.

1) Debrided 2 x 3cm Right 1st MTPJ skin ulcer = 97597

2) Debrided 2 x 1cm subcutaneous ulceration plantar 2nd metatarsal head as well as the subcutaneous 5 x 4 right leg ulceration = total 22 sq cm = 11042 for the first 20 sq. cm. plus 11045 for additional 2sq. cm.

3) Debrided 7 x 4cm necrotic Achilles tendon ulceration = 11043 for the first 20 sq. cm. and 11046 for additional 8 sq. cm.

4) Debrided 0.5 x 0.5cm necrotic bone on the left lateral malleolus = 11044


CPT 97597

Debridement (e.g., high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/ or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed, and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq. cm. or less. This code is to be used when only skin structures were debrided. It is to be used for up to and including 20 sq. cm. of tissue debrided. There is a 0 day global and the relative value unit is 2.52.


(CPT 97597/97598 coding example: If you debrided a 47 sq. cm. skin wound, you would code: 97597 x 1 for the first 20 sq. cm., plus 97598 x 2 for sq. cm. 21-40 and sq. cm. 41-47. The total RVU would be 2.52 + 0.79 + 0.79 = 4.10.)


Billing and Coding Guidelines for Wound Care

Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.

2. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.

3. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.


4. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their plan of care. If it is a physician or non-physician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements

Thursday, April 15, 2021

CPT code G0104, G0105, G0121 - Colorectal cancer screening

 CPT code and Description


G0105 Colorectal cancer screening; colonoscopy on individual at high risk

G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy



SUMMARY OF CHANGES: The method for calculating payment for discontinued procedures is being revised. New payment rates will apply when modifier 53 (discontinued procedure) is appended to codes 44388, 45378, G0105, and G0121.


GENERAL INFORMATION


A. Background: Prior to calendar year (CY) 2015, according to Current Procedural Terminology (CPT) instruction, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Physicians were previously instructed to report an incomplete colonoscopy with 45378 and append modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy.

In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states, “When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is

unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.” Therefore, in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) has applied specific values in the Medicare physician fee schedule database for the following codes: 44388-53, 45378-53, G0105-53, and 

G0121-53.


B. Policy: Effective for services performed on or after January 1, 2016, the Medicare physician fee schedule database will have specific values for codes 44388-53, 45378-53, G0105-53, and G0121-53. Given that the new CPT definition of an incomplete colonoscopy also includes colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum, CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. Incomplete colonoscopies are reported with the 53 modifier. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.


Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)


An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.


• HCPCS G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.


G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy


Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below. For claims with dates of service on or after January 1, 2002, contractors pay for screening flexible sigmoidoscopies (HCPCS G0104) for beneficiaries who have attained age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in §1861(aa)(5) of the Social Security Act (the Act) and in the Code of Federal Regulations (CFR) at 42 CFR 410.74, 410.75, and 410.76) at the frequencies noted above. For claims with dates of service prior to January 1, 2002, Medicare Administrative Contractors (MACs) pay for these services

under the conditions noted only when a doctor of medicine or osteopathy performs them.

For services furnished from January 1, 1998, through June 30, 2001, inclusive:


• Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was performed).

For services furnished on or after July 1, 2001:


• Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §60.3 of this chapter) and he/she has had a screening colonoscopy (HCPCS G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (HCPCS G0121).


NOTE: If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth; the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal along with modifier –PT should be billed and paid rather than HCPCS G0104.


When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances (see chapter 12, section 30.1), Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes. The Medicare physician fee schedule database has specific

values for codes 44388-53, 45378-53, G0105-53 and G0121-53. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure as long as coverage conditions are met. This policy is applied to both screening and diagnostic colonoscopies. When submitting a claim for the interrupted colonoscopy, professional providers are to suffix the colonoscopy code with a modifier of “–53” to indicate that the procedure was interrupted. When submitting a claim for the facility fee associated with this procedure, Ambulatory Surgical Centers (ASCs) are to suffix the colonoscopy code with modifier “–73” or “–74” as appropriate. Payment for covered screening colonoscopies, including that for the associated ASC facility fee when applicable, shall be consistent with payment for diagnostic colonoscopies, whether the procedure is complete or incomplete.

Note that Medicare would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the contractor to document the incomplete procedure.


HCPCS G0121 - Colorectal Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk - Applicable On and After July 1, 2001

Effective for services furnished on or after July 1, 2001, screening colonoscopies (HCPCS G0121) performed on individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §60.3 of this chapter) may be paid under the following conditions:


• At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered HCPCS G0121 screening colonoscopy was performed.)


• If the individual would otherwise qualify to have covered a HCPCS G0121 screening colonoscopy based on the above but has had a covered screening flexible sigmoidoscopy (HCPCS G0104), then he or she may have covered a HCPCS G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered HCPCS G0104 flexible sigmoidoscopy was performed.


NOTE: If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal along with modifier –PT should be billed and paid rather than HCPCS G0121.



Colonoscopy – CPT Codes 45378-45398, G0105, G0121


The American Society for Gastrointestinal Endoscopy (ASGE) works to ensure that adequate methods are in place for gastroenterology practices to report and obtain fair and reasonable reimbursement for procedures, tests and visits. To assist practices in understanding and implementing GI-specific coding, ASGE has developed coding sheets. The purpose of the coding sheet is to provide a high-level overview to support practices in there coding and reimbursement for 2018. 


What is a Colonoscopy?


It is an examination of the entire colon, from the rectum to the cecum, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.

The CPT© codes in this series identify services performed during Colonoscopy


HCPCS Codes for Colonoscopy

HCPCS Code Code Descriptor

G0105 Colorectal cancer screening; colonoscopy on individual at high risk

G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk



Gastroenterology Coding: Screening Versus Diagnostic Colonoscopy


To define the procedure, a colonoscopy is the examination of the entire colon from the rectum to the cecum, and it may include examination of the terminal ileum (small intestine). With that being said, there are two types of colonoscopies: screening and diagnostic. Medicare has specific guidelines for screening and diagnostic colonoscopies. Other payers may have very specific criteria for both types of colonoscopies as well.


Medicare defines these two types as:


1. Screening – used for patients who have:

• No family history of colon cancer or colon polyps

• No personal history of colon cancer or polyps

• No symptoms before the procedure (abdominal cramping, blood in the stool, weight loss, anemia, vomiting)


2. Diagnostic – used for patients who have:

• Family history of colon cancer or polyps

• Personal history of colon cancer or polyps

• Symptoms before the procedure (abdominal cramping, blood in the stool, weight loss, anemia, vomiting)

• Previous colonoscopy(ies) with findings of polyps, colon cancer, diverticulitis, etc.


Medicare also defines what they consider to be high risk for colorectal cancer as an individual with:

• A close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp

• A family history of familial adenomatous polyposis

• A family history of hereditary nonpolyposis colorectal cancer

• A personal history of adenomatous polyps;

• A personal history of colorectal cancer; or

• Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis


Medicare uses HCPCS codes to bill for screening colonoscopies. For a patient of typical risk, the screening procedure is reported with HCPCS code G0121; for a

patient at high risk, it is reported with HCPCS code G0105. Providers should review the policies of their insurance payers to be certain which coding system is

used, especially for Medicare Advantage plans offered by commercial insurers.

Per the 2019 AMA CPT Professional Edition guidelines:


When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colonsmall intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.


If a therapeutic colonoscopy (44389-44407, 45379, 45380, 45381, 45382, 45384, 45388, 45398) is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

For colonoscopy through stoma, see 44388-44408.


So, the first step to coding a colonoscopy is to determine if it is a screening or diagnostic colonoscopy. If the patient has had any signs or symptoms such as

abdominal pain, weight loss or rectal bleeding, then it is not a screening but rather a diagnostic (symptomatic) colonoscopy. Also, if the patient has had

previous findings such as polyps or diverticulitis, then it is not a screening colonoscopy.

Aside from the CPT coding guidelines, if you’re wondering what the current Medicare reimbursement rates are for selected GI services, GI.org has a helpful

chart.


Keeping track of gastroenterology code changes should not fall solely on you or your staff. You should have tools in place like a gastroenterology EHR system that

can help in the process.



providing the correct procedure codes to report colonoscopies continues to cause confusion for the professional coder. The American Medical Association (AMA) provides the Common Procedural Terminology (CPT) codes used to report outpatient procedures for hospitals and physicians. Medicare adds additional codes in the HCPCS  Healthcare Procedure Coding System). HCPCS includes both CPT, which is HCPCS Level I, and CMS-developed HCPCS Level II codes. The HCPCS codes are required for all Medicare outpatient hospital services, if they are available, unless specifically excepted in Medicare manual instructions. Let us take a look at some typical colonoscopy coding scenarios, and the CPT and HCPCS codes that should be reported.


Screening colonoscopy


AHA Coding Clinic provides guidance in assigning the principal or first-listed diagnosis code when the physician documents that the colonoscopy is performed for screening purposes only. Code V76.51 is used first and any findings such as polyps, diverticulosis, or hemorrhoids are listed second; see Coding Clinic, First Quarter 1999 Page: 4. CPT codes are reported based on the procedure documented, and whether the patient is Medicare. If the patient is not Medicare, the appropriate CPT, (HCPCS Level I) code is assigned. If the patient is Medicare and no other procedures, such as a polypectomy or biopsy are performed, then either code G0105 or G0121,

(HCPCSL Level II) codes are assigned. G0105 is assigned if the patient qualifies as high risk using the following criteria:


* A personal history of colorectal cancer or

* A family history of familial adenomatous polyposis or

* A family history of hereditary nonpolyposis colorectal cancer or

* A personal history of adenomatous polyps or

* Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis or

* A close relative (sibling, parent, or child) has had colorectal cancer or an adenomatous polyp.

HCPCS code G0121 is assigned if the patient does not qualify as high risk.

Screening colonoscopy with polypectomy

If the colonoscopy starts as a screening, but the physician finds polyps and performs a polypectomy, the principal or first-listed diagnosis code remains as V76.51. The polyp is reported as a secondary diagnosis code. The procedure reported will depend on the documentation and will include only the CPT, Level I HCPCS code(s). Medicare also requires the modifier PT to be added to the procedure code, when the screening colonoscopy becomes a diagnostic colonoscopy. Use of this modifier will allow the Medicare patient to have the deductible waved.

Colonoscopy with different polypectomy techniques

When the colonoscopy includes more than one polypectomy technique, each technique may be reported separately if performed on different polyp sites. For example the physician performs a cold forceps polypectomy on a polyp in the descending colon, a polypectomy using snare in the rectum, and a polypectomy using hot forceps in the rectum.

Each procedure is reported using modifier 59 for the second two; see Coding Clinic for HCPCS - Third Quarter 2006 Page: 4. If two techniques are used on the same polyp, such as a snare removal followed by hot cautery, only the hot cautery should be reported; see CPT Assistant January 2004, pages 5-7.

Colonoscopy with tattooing

Occasionally, the physician injects ink to identify a polypectomy or other suspicious sites in the colon when performing the colonoscopy. CPT code 45381, colonoscopy with submucosal injection, should be reported in addition to the polypectomy or other procedure; see CPT Assistant, June, 2010, page 4. A separate procedure modifier 59 is not required. 

Colonoscopy with upper endoscopy

Quite often a colonoscopy is performed either just prior to, or just following an upper endoscopy, or esophagogastroduodenoscopy, (EGD). When this situation occurs, both the code for the colonoscopy and the EGD are reported. Modifier 59 is not required as the procedures are performed in different body systems. A high percentage of modifier 59 use could prompt a focus review by an outside agency.

It is important to understand the colonoscopy coding guidelines and associated procedures for both coding compliance and to obtain the correct reimbursement due to the facility. Performing routine audits to check the coding of this procedure will help to ensure proper coding.

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