Diagnostic Colonoscopy

A diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign, or symptom (such as diarrhea, abdominal pain, etc.).

Factors for Consideration:

  • Symptoms before the procedure such as a change in bowel habits, rectal bleeding, etc.
  • Findings during the procedure (polyp, cancer, diverticulosis, etc.)
  • Personal history of cancer or polyps
  • Family history of cancer or polyps

If a patient acknowledges any symptoms when scheduling the colonoscopy, he or she should be informed that the procedure is diagnostic and not screening in nature. According to the AGA, the endoscopist will have to make a clinical decision as to whether or not the symptoms warrant a diagnostic procedure, or if the symptoms are insignificant enough for the procedure to remain a screening.

If a polyp or lesion is found during the screening procedure, the colonoscopy becomes diagnostic and should be reported with the appropriate diagnostic colonoscopy code (45378-45392). For Medicare patients, the PT modifier would be appended to the code to indicate that this procedure began as a screening test.

Screening Colonoscopy

A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not change the screening designation of that procedure.

Factors for Consideration:

  • No symptoms before the procedure
  • No findings during the procedure (polyps, diverticulosis, etc.)
  • No personal history of cancer of polyp
  • No family history of cancer or polyp. When a patient has history of colon polyp or cancer with no current symptoms, these colonoscopies are considered high-risk screening procedures

For commercial and Medicaid patients, use CPT code 45378 (Colonoscopy, flexible, proximal to splenic flexure diagnostic with or without collection of specimen(s) by brushing or washing, when performed (separate procedure).

For Medicare beneficiaries, use HCPCS code G0105 (Colorectal cancer screening, colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening, colonoscopy on individual not meeting the criteria for high risk) as appropriate.

When the physician removes one or more polyp at the time of the screening colonoscopy; because the procedure was initiated as a screening, the screening diagnosis is primary and the polyp(s) is secondary. The endoscopist reports the appropriate code for the diagnostic or therapeutic procedure performed.

Example: CPT code 45379-45392.

Modifiers used with colonoscopy

PT – CMS developed this PT modifier to indicate that a colonoscopy that was scheduled as a screening was converted to a diagnostic or therapeutic procedure.

33 – CPT developed this 33 modifier for preventive services, when the primary purpose of the service is the delivery of an evidence-based service.

53 – If a patient is scheduled for a screening colonoscopy, but because of poor prep the scope cannot be advanced beyond the splenic fixture, Per Medicare guidelines the procedure should be coded as a colonoscopy with a 53 modifier (discontinued procedure*). Even if the scope was advanced beyond the splenic fixture but the visualization was poor and the physician wants to repeat the procedure within the restricted time period, add the 53 modifier.

74 -When the colonoscopy is not documented as advanced at least into the transverse colon, append Modifier 74 (discontinued outpatient procedure after anesthesia administration). The operative report must state why and when the procedure was discontinued. The extent and/or percentage to which the procedure was performed also should be documented.

73 – When the procedure is cancelled prior to the insertion of the colonoscopy, append modifier 73 (discontinued outpatient procedure prior to anesthesia administration).

The patient’s chart must document the following:

  • Why and when the procedure was cancelled.
  • The patient was taken to the room where the colonoscopy was to be performed.
  • Anesthesia/sedation was not administered, and the colonoscopy was not inserted.

If the procedure was cancelled or rescheduled for the convenience of the patient, physician, or facility, the procedure is not reportable or eligible for payment.

*A colonoscopy is considered complete when the endoscope is passed proximal to the splenic fixture.