2016 Physician Coding Survival Guide
Chapter 7: GastroenterologyCancer Screening: Cross Out 4 Checklist Items to Claim Colorectal Cancer Screening Payment Look out for screening tests that are not covered for payment.
Billing colorectal cancer screenings for asymptomatic patients is a challenge for many gastroenterology practices because each state Medicare carrier may have its own rules concerning how to bill for these procedures. Although Medicare coverage of various colorectal cancer screening examinations is payable, you need to be precise using ICD-10 and HCPCS codes to maximize reimbursement.
Tick off all items in this checklist before submitting the claim for colorectal screening and see your physician get his deserved reimbursement.
Item #1: Justify Patient Risk Status With Supported Diagnostic Codes
Although all persons above 50 years of age are eligible for colorectal cancer screening tests even in absence of any symptoms, a patient must fall into the high-risk category for colorectal cancer to qualify for a screening colonoscopy or screening barium enema before age 50. For a patient to be classified as high risk, you have to use a certain diagnosis. You won’t get paid just because the patient has colorectal cancer screening as a benefit.
According to the American Cancer Society, the following conditions make your risk higher than average: A personal history of colorectal cancer or adenomatous polyps
A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease) A strong family history of colorectal cancer or polyps
A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or hereditary nonpolyposis colon cancer (HNPCC).
To be reimbursed for the screening, you must check the gastroenterologist’s notes to include an accepted diagnosis code denoting the high-risk status of the patient with the procedure code. The following ICD-10 codes are some examples of diagnoses that meet the high-risk criteria for colorectal cancer:
Z12.11 -- Encounter for screening for malignant neoplasm of colon Z12.12 -- Encounter for screening for malignant neoplasm of rectum Z80.0 -- Family history of malignant neoplasm of digestive organs Z83.71 -- Family history of colonic polyps
Z85.00- Personal history of malignant neoplasm of unspecified digestive organ Z85.810 -- Personal history of malignant neoplasm of tongue
Z86.010 -- Personal history of colonic polyps
Other than these primary diagnoses, some secondary diagnoses from among the following family of diagnostic codes may also apply:
K50.-- (Crohn’s disease [regional enteritis]) K51.-- (Ulcerative colitis)
K52.-- (Other and unspecified noninfective gastroenteritis and colitis)
The final determination of what is an appropriate diagnosis for being at high risk has been left with the state Medicare payers, however, and the codes that each one will accept can vary significantly.
Item #2: Check Screening Frequency Rules
Medicare’s coverage of colorectal screening tests for patients includes multiple procedures available to an individual for the early detection of cancer. Although people of any age are eligible for a colonoscopy, all other tests are covered for people age 50 or older. The frequency restrictions for these tests depend on the patient’s risk category.
Check through the following list for deciding eligibility for average risk/asymptomatic patients (beginning at age 50 years and continuing until age 75 years):
Screening fecal occult blood test (FOBT) — Once every 12 months.
Screening flexible sigmoidoscopy — Once every 48 months after the last flexible sigmoidoscopy or barium enema, or 120 months after a previous screening colonoscopy.
Screening colonoscopy — Once every 120 months, or 48 months after a previous flexible sigmoidoscopy. Screening barium enema — Once every 48 months when used instead of sigmoidoscopy or colonoscopy. Multi-target stool DNA test (like Cologuard™) — Once every 3 years for people who meet all of these conditions: They’re between 50–85.
1.
They show no signs or symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, 2.
blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test.
They’re at average risk for developing colorectal cancer, meaning they have no personal history of adenomatous 3.
polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis. They have no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or 4.
hereditary nonpolyposis colorectal cancer.
The frequency rules for high-risk patients (No age restriction) are: Screening barium enema — Once every 24 months Screening colonoscopy — Once every 24 months.
One other option listed in some places, as a primary screening test is Computed tomography colonography (CTC). “However, virtual CT is not indicated for primary screening,” cautions. “Some states have their own regulations for non Medicare. For Medicare, it may be covered under certain condition such as failed optical colonoscopy or some severe co-morbid health conditions.”
Exception: Other than the tests mentioned above, physicians may also order one of the following tests for screening. However, watch out, as these are noncovered colorectal cancer screening tests:
Magnetic resonance imaging (MRI) colonography is considered experimental and investigational for the screening 1.
or diagnosis of colorectal cancer, inflammatory bowel disease, or other indications because its value for these indications has not been established.
Wireless Capsule Endoscopy (WCE) -- WCE (i.e. PillCamTM) is accomplished by encasing video, illumination and 2.
transmission modules inside a capsule the size of a large vitamin pill. WCE is NOT a covered benefit for general screening.
Virtual Colonoscopy or CT Colography – Several states have their own rules about coverage of CT colography for 3.
non Medicare patients so you may need to check your own state’s rules to determine if this test is covered for primary colorectal cancer screening.
Item #3: Pick the Proper Screening HCPCS Code
In addition to using the correct diagnosis code, gastroenterologists should bill their Medicare claims for asymptomatic patients with the proper HCPCS code for the specific screening service provided.
You should use the following HCPCS codes with Medicare claims for colorectal cancer screening services for high-risk patients:
- G0104 -- Colorectal cancer screening; flexible sigmoidoscopy;
- G0105 -- Colorectal cancer screening; colonoscopy on individual at high risk;
- G0106 -- Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema - G0120 -- Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema - 82270 -- Screening FOBT (Blood, occult, by peroxidase activity…);
- G0328 -- Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous.
For billing a colorectal cancer screening test for an average/ no risk individual, you should choose from these two HCPCS codes:
- G0121 -- Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk - G0122 -- Colorectal cancer screening; barium enema
Gastroenterologists using code G0121 should do so when the patient fits the once every 10 year interval and should not be surprised to see a Medicare denial if the prior colonoscopy was less than 10 years. In that case the physician may not be able to bill the patient for the service unless an Advanced Beneficiary Notice was obtained.
Item #4: Separate Screening From Diagnostic Services
You should not confuse codes used to report colorectal screening services with the CPT® codes used to report diagnostic services. The HCPCS codes are used when the patient is asymptomatic, regardless of whether he or she is at high risk for colorectal cancer.
If the patient comes in with a symptom such as blood in stool and the gastroenterologist performs a colonoscopy, then you should bill the appropriate sigmoidoscopy or colonoscopy procedure codes 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) or 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) for the diagnostic service.
Likewise, fecal-occult blood tests for diagnostic evaluation of symptomatic patients should be billed using the CPT® code 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous
determinations).
If the GI converts a screening test into a diagnostic endoscopy due to abnormal findings, you should bill the appropriate CPT® code with modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) instead of the screening code.
Gastroenterologists also should ensure that patients referred to them for colorectal screenings are actually asymptomatic. Many times patients are referred for a screening when they really have symptoms, and those procedures should be coded as diagnostic.
Part B Payment: Check How CMS Final Payment Rules Affect Your Practice in 2016 Here’s why you should prepare for deeper pay cuts.
CMS released its Final Rule on Oct. 30, outlining how it will pay for services under the Medicare Physician Fee Schedule in 2016, which included comments and explanations of how CMS set payments for both old and new services.
Here’s How Your Gastro Practice Will See Damage
Although most specialists will see overall reimbursement remain fairly stable in 2016, gastroenterologists will take an overall four percent hit to their payments effective Jan. 1, due to adjustments in endoscopic lower GI procedures, including colonoscopies. For example, payment for 44394 (Colonoscopy through stoma…) will drop from 4.42 RVUs this year to 4.13 RVUs starting in January. Other gastroenterology services will follow suit.
Although CMS projects overall cuts of four percent, the actual damage could be higher, depending on the mix of services that your doctors perform. For instance, the final rule notes that CMS will lower the work RVUs for code 45380
(Colonoscopy, flexible; with biopsy, single or multiple) to 3.66 from its current level of 4.43, resulting in more than a 17 percent hit to this service.
Societies React: The American Gastroenterological Association noted that it was “outraged” at the “inappropriately deep” cuts, which the association had urged CMS not to adopt when the proposed rule came out last summer. Many medical societies are contacting Congress members and CMS executives to explain how severely these cuts will impact gastroenterologists.
CMS Sets Payment Rules for Advance Care Planning
The codes have been in your CPT® book since January, but with CMS establishing no payment for advance care planning, your practice was left empty-handed—until now. Effective Jan. 1, 2016, you will be able to collect for your practitioners’ services in talking about end-of-life decisions with Medicare beneficiaries.
“CMS is establishing separate payment and a payment rate for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners,” the agency said in a Fact Sheet about the decision. “The Medicare statute currently provides coverage for advance care planning under the ‘Welcome to Medicare’ visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment for advance care planning codes to recognize additional practitioner time to conduct these conversations provides
beneficiaries and practitioner’s greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families.”
The CPT® codes that describe these services are as follows:
99497: Advance care planning including the explanation and discussion of advance directives such as standard forms [with completion of such forms, when performed], by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member[s], and/or surrogate
+99498.. each additional 30 minutes..
Payment is set: The agency assigned 1.50 work RVUs to 99497 and 1.40 RVUs to 99498. Officials noted that this will translate into payments of about $86 for 99497 and $75 for the add-on code 99498.
According to the Final Rule, you can report 99497 and 99498 on the same date as other E/M services, transitional care management and chronic care management, and you can even bill them during global surgical periods. You cannot, however, report 99497 and 99498 on the same date as certain critical care services including neonatal and pediatric critical care, the Final Rule indicates.
Look for Conversion Factor to Drop
On the negative side, doctors who were looking for a 0.5 percent pay boost—as promised as part of MACRA, which was passed earlier this year—will be disappointed. Although MACRA said that payments would increase by 0.5 percent every year from 2016 through 2019, the Final Rule suggests otherwise.
The conversion factor is actually dropping from the current level of 35.9335 to 35.8279, the Final Rule says. Although CMS did increase the conversion factor by 0.5 percent, the agency then cut it by -0.02 percent due to a “budget neutrality adjustment” and another -0.77 percent attributed to a “target recapture amount,” resulting in a total cut of 0.3 percent
instead of the 0.5 percent raise that doctors had expected. Resource: To read the entire Final Rule,
visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-28005.pdf or read the Fact Sheet at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-2.html.
