Professional fee coding is the billing for physicians. The facility coding is billing for the facility and the equipment.
A screening test is a test provided to a patient in the absence of signs or symptoms. A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure. As part of the Affordable Care Act (ACA), Medicare and most third-party payors are required to cover services given an A or B rating by the U.S. Preventive Services Task Force (USPSTF) without a co-pay or deductible, but the correct CPT and ICD-10-CM codes must be submitted to trigger coverage at 100% for the patient. See the
AGA coding guide for CRC screening to learn what codes to use and know what patients can usually expect to pay depending on whether they have commercial insurance or Original Medicare.
Diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign or symptom (such as abdominal pain, bleeding, diarrhea, etc.). Medicare and most commercial payors do not waive the co-pay and deductible when the intent of the visit is to perform a diagnostic colonoscopy.
If a polyp or lesion is found during the screening procedure, the colonoscopy should be reported with the appropriate diagnostic colonoscopy code (45378-45392) based on the procedure performed. For Medicare patients, add PT modifier to the code to indicate that this procedure began as a screening test. For patients with commercial insurance, add modifier -33.
CMS developed the PT modifier to indicate that a colonoscopy that was scheduled as a screening was converted to a diagnostic or therapeutic procedure. The PT modifier (
Colorectal cancer screening test, converted to diagnostic test or other procedure) is appended to the CPT procedure code for Medicare claims.
CPT developed modifier 33 for preventive services, “when the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure.” Modifier -33 is used for commercial insurance claims.
For example, if a physician performing a screening colonoscopy on a patient with commercial insurance finds and removes a polyp with a snare, use CPT code 45385 and append modifier 33 to the CPT code. If the patient is a Medicare beneficiary, use CPT code 45385 with modifier PT.
Procedure codes for commercial insurance and Medicare
Select the appropriate code based on the type of removal performed. If multiple polyps/lesions were removed using different techniques, report each method separately.
NOTE: You must add modifier 33 or PT (see below) to identify the polypectomy as a screening service and prevent the patient from being inappropriately billed.
| 45380 | Colonoscopy, flexible; with biopsy, single or multiple |
| 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 |
| 45388 | Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) |
| Modifiers | – Add modifier 33 (preventative services) to each CPT code for commercial insurance
– Add modifier PT (colorectal cancer screening test; converted to diagnostic test or other procedure) to each CPT code for Medicare |
ICD-10-CM codes
| Z12.11 | Encounter for screening for malignant neoplasm of the colon (Note: this code must be listed first when reporting multiple diagnosis codes) |
| Z12.12 | Encounter for screening for malignant neoplasm of rectum (Note: this code must be listed first when reporting multiple diagnosis codes) |
| D12.0 | Benign neoplasm of the cecum |
| D12.4 | Benign neoplasm of the descending colon |
| D12.8 | Benign neoplasm of the rectum |
Insurance coverage
| Commercial insurance | Colonoscopy, bowel prep, sedation, lab work and the hospital or ambulatory surgery center costs where the colonoscopy with polypectomy was performed are covered 100% by health insurance. |
| Medicare | In 2022, if a polyp is removed the patient is responsible for 20% of the cost. From 2023 to 2026, patient responsibility is 15% of the cost, from 2027 to 2029 it falls to 10% and by 2030 it will be covered 100% by Medicare. |
Use this page to view details for the Local Coverage Article for billing and coding: screening colonoscopy converted to a diagnostic and/or therapeutic colonoscopy.
www.cms.gov
