The coding of screening colonoscopies can be a challenge due to conflicting documentation in medical records. A screening is an exam in a seemingly healthy individual due to a characteristic such as age, gender or occupational exposure. A screening is not meant to study the cause of gastrointestinal (GI) symptoms such as abdominal paid or bleeding – that is considered a diagnostic exam and is coded differently than a screening.
It is best practice that a provider clarifies the intent of the exam whenever a patient is scheduled for a screening, but also has concurrent GI symptoms. If a patient is scheduled for a screening and presents with incidental GI symptoms this would not preclude coding a screening: however, the provider should clarify this in the medical record.
Sometimes during a screening colonoscopy, a polyp is found and removed. This scenario requires careful attention to both coding and billing, in order for correct claims adjudication.
The case is still coded with a primary diagnosis of screening (Z12.11). Modifier PT (for Medicare) or 33 (for commercial insurers) is appended to the CPT polypectomy code (eg, 45384). In addition, the biller must link the polyp diagnosis code (eg, K635, D124) to the polypectomy code (45384) on the CMS 1500 in order to bypass claim edits. This is accomplished by entering a diagnosis pointer of “B” or “2” in box 24 E as the polyp will be the second code reported, the primary code still remains a screening (Z1211).
This concept of linking diagnoses to procedures in order to meet medical necessity may not be well understood in billing, and incorrect practices like omitting Z12.11 from the claim should be avoided in order for coding to comply with official coding guidelines.