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This month’s column addresses coding and reimbursement questions
regarding a procedure
performed by many general
surgeons: colonoscopy.
Coding issues
Much of the confusion
with respect to coding for
colonoscopy arises from the
dichotomy between screening
and diagnostic colonoscopy.
Screening colonoscopy is defined
as a procedure performed on an
individual without symptoms to
test for the presence of colorectal
cancer or polyps. Discovery
of a polyp or cancer during a
screening exam does not change
the screening intent. Surveillance
colonoscopy is a subset of
screening, performed at an
interval less than the standard 10
years from the last colonoscopy
(or sooner, in certain high-risk
patients), due to findings of cancer
or polyps on the previous exam.
The patient in this case is also
asymptomatic. Unlike the two
procedures mentioned previously,
a diagnostic colonoscopy allows
physicians to evaluate symptoms,
such as anemia, rectal bleeding,
abdominal pain, or diarrhea.
Understanding the difference
between screening and
diagnostic colonoscopies has
become increasingly important
in recent years, especially after
the enactment of the Affordable
Care Act, which mandates
that insurers pay the full cost
of screening examinations
without collecting a deductible
or copayments from patients.
Consequently, endoscopists
saw an increase in the volume
of screening examinations
beginning in 2011. Unfortunately,
many of them also experienced
an increase in calls from
patients regarding their bills.
A screening colonoscopy
should be reported with
the following International
Classification of Diseases,
10th edition (ICD- 10) codes:
• Z12.11: Encounter for screening
for malignant neoplasm of the
colon
•Z80.0: Family history of malignant
neoplasm of digestive organs
•Z86.010: Personal history of
colonic polyps
If a polyp is found and
removed during the same
procedure, these codes should
still be listed as the primary
diagnosis codes, followed by
the appropriate ICD- 10 code
for polyp: D12.0–D12.9 (benign
neoplasm of the colon or
rectum, based on location).
All Current Procedural
Terminology (CPT) codes
for colonoscopy were revised
for 2015.* Several new CPT
codes were introduced for
interventional colonoscopy
procedures, which were not
valued for 2015; however, all of
these codes have been valued
Coding and reimbursement
for colonoscopy
by Mark T. Savarise, MD, FACS
*All specific references to CPT codes and
descriptions are © 2016 American Medical
Association. All rights reserved. CPT and
CodeManager are registered trademarks
of the American Medical Association.
