october 2014

Colonoscopy Guideline Changes for 2015

Let’s start with the current guidelines.

“When performing an endoscopy on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope beyond the splenic flexure, due to unforeseen circumstances, report the colonoscopy code with modifier 53 and appropriate documentation.”

In this instance when the scope is advanced into the colon but does not traverse the splenic flexure and go into the transverse colon the coder should report the appropriate colonoscopy code, for example 45378 for a diagnostic procedure or 45380-45385 if a biopsy was taken or a polypectomy was performed. Modifier usage is dependent upon whether you are coding for the physician (modifier -53) or for the ASC (modifier -74).

Now let’s look at the changes for 2015.

1.“Report flexible sigmoidoscopy (45330-45347) for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure.”

Based on this new guideline instead of billing the appropriate colonoscopy code with modifier -74 we should now be reporting a sigmoidoscopy code instead.

2.“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.”

This guideline is similar to the original guideline except that in the original it stated “beyond the splenic flexure” and the new guideline states “to the cecum or colon-small intestine anastomosis.” Keep in mind however, that modifier -53 or -74 would be appended only when it is a diagnostic colonoscopy (no surgical procedures performed).

3.“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.”

So when a procedure is performed such as a polypectomy and the scope does not reach the cecum or colon-small intestine anastomosis modifier -52 is appended rather than modifier -53 or -74.

Short version: When scope does not pass proximal to the splenic flexure report the appropriate sigmoidoscopy code. When scope goes beyond the splenic flexure but not to the cecum/colon-small intestine anastomosis and is a diagnostic procedure only, report the appropriate diagnostic colonoscopy/colonoscopy through stoma code with modifier -53 or -74. When the scope goes beyond the splenic flexure but not to the cecum/colon-small intestine anastomosis and a therapeutic procedure is performed, report he appropriate colonoscopy/colonoscopy through stoma code with modifier -52.







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