Medicare Rule Regarding Colonoscopies

Q

We have been working with our coders to better help them understand modifiers XS and XU. When reporting two or more diagnostic colonoscopy codes, is it appropriate to append modifier XS (separate structure), or should we report modifier XU (unusual, non-overlapping service)? For example, we need to append a modifier to report 45380 with 45385 to resolve a CCI edit.

A

The modifier assignment will be dependent on the site of the polyp being removed. If all polyps removed are in the large intestine and each removed by a different method (i.e., cold biopsy, hot biopsy, snare), append modifier XU. The large intestine starts at the sigmoid colon and ends at the cecum.

This is considered one anatomic site.

Consider these two scenarios.
Scenario 1:
The patient presents for a colonoscopy. The scope is advanced to the cecum. During the exam two polyps are identified. The first polyp is identified in the descending colon and removed by cold biopsy. The second polyp is identified in the transverse colon and removed by hot biopsy.

In this scenario, report 45384 for the hot biopsy of polyp in the transverse colon and 45380 for the cold biopsy removal of a polyp in the descending colon. Append modifier XU to 45380 for overlapping services. Although the polyps are identified at different areas of the large intestine, they were in the same anatomic site. The services are considered overlapping since the polyps were removed in different methods (i.e., cold biopsy and hot biopsy).

Scenario 2:
The patient presents for a colonoscopy. The scope is advanced to the cecum. During the exam two polyps are identified. The first polyp is identified in the rectum and removed by cold biopsy. The second polyp is identified in the transverse colon and removed by hot biopsy.

In this scenario, report 45384 for the hot biopsy of polyp in the transverse colon and 45380 for the cold biopsy removal of a polyp in the rectum. Append modifier XS to 45380 for separate anatomic site. One polyp was identified in the large intestine and the other polyp was in the rectum. Since the rectum is a different anatomic site from the large intestine, XS is appropriate.

Q

We have been holding bills at our Rural Health Clinic for pre-operative clearance visits for Medicare patients scheduled for a colonoscopy. I have been asked to investigate whether these encounters are billable. We have heard that E/Ms “before/prior to” a screening C-scope were not to be billed. However, for the 16 years I have been in clinic billing we have always billed them if they weren’t the “day before or day of” of procedure, as those would get bundled. We’ve gotten paid just fine and in all those years to my knowledge, none of our MC audits resulted in any take backs or fines regarding our billing them.

We researched coding forums on-line as well, and any data I could find from or regarding MC and screening C-scopes and opinion, is divided. Many stated that the “before/prior to” means within 24 hours of the procedure; and that they have billed for them as a rule and always been paid (as we did). Others said they felt that the “before/prior to” meant any time, even weeks before, and they didn’t bill for them.

Is the “consulting/decision for surgery” visit to a specialist for a screening colonoscopy billable?
We understand that a pre-operative clearance/H&P after the decision for surgery is made, is not billable as it is not deemed medically necessary. But can we bill for the visit in which the patient meets the specialist, and a decision is made as to whether or a colonoscopy should be done or not?

Also, if the consult/decision for surgery is indeed billable, does it fall into the “day before/day of “rule where it’s not billable even with modifier 57, due to being a minor procedure, or is that rule only regarding pre-ops? Typically, our consults are done days to weeks prior to the scope, but sometimes it is more of a list-minute decision.

A

Medicare and most other insurers cover only medically necessary services. A patient is eligible for a screening colonoscopy if there are no signs or symptoms of GI trouble. It stands to reason that a pre-op clearance exam that finds no health care condition to support the medical necessity of the visit is not medically necessary, and therefore should not be billed, regardless of the timing (same day or not.) Medicare may have paid claims for such visits at the RHC in the past, but that doesn’t necessarily mean the visits have truly met the general test of medical necessity.

However, if there is a medically necessary reason for the visit, such as any other complicating condition that would be pertinent to the safety of the patient while undergoing the procedure (high blood pressure, diabetes, etc.), then the visit might be considered medically necessary. Medical necessity will be determined by the documentation and diagnosis coding provided in addition to the ICD10 Z01.81x (Encounter for preprocedural examinations.) 
Medicare defines an RHC visit as “medically necessary”.

The American Gastroenterological Association website also discusses this issue.

If the service is not a screening colonoscopy, then several other factors influence whether a pre-operative H&P visit should be separately reported and/or reimbursed:

As you may already be aware, Medicare assigns a “global” period indicator of 000 to most colonoscopy codes − “000” − Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.”

Surgeons may bill for a visit prior to surgery, as they need to evaluate the problem and determine the best surgical approach, but:

Another physician (not the surgeon) can bill for an H&P after the surgeon makes the decision to perform surgery, and refers the patient to a second physician (often a primary care physician) for a preoperative H&P.

This service is reportable, but if the visit is not deemed to be medically necessary, a payor may deny payment. Medical necessity will be determined by the documentation and diagnosis coding provided in addition to the ICD10 Z01.81x:

ICD-10 Codes
Codes and/or Descriptions: Z0181

The following matric was created to help simplify the various scenarios when a medically necessary pre-op exam would be billable: