Controversial rules, however, complicate this topic.
Colorectal cancer screening consists of the combination of the fecal occult blood test and the follow up colonoscopy.
Who would have thought that this topic would be so controversial or complicated, but I am going to revisit the Cologuard®/colonoscopy discussion, hopefully one last time.
Let us all remember that different rules, guidelines, and advice have different timelines. The Coding Clinic comes out every quarter and the Official Guidelines are revised once or twice a year. MLN Matters sheets come out at the whim of Medicare. The objective of documenting and coding diagnoses and procedures is to tell the truth of the patient encounter, with a secondary goal of getting paid for it.
As of January 1, 2023, Medicare coverage for colorectal cancer screening (notated as CRC screening in the transmittal) changed. Perhaps, we should thank the Black Panther for this updated coverage. Chadwick Boseman was a talented actor who died at the age of 43 from colon cancer in August 2020. He played the role of King T’Challa, the Black Panther, while undergoing chemotherapy treatment under secrecy of his diagnosis. When he died, it profoundly affected many, including me. It reminded me of one of the kindest nurses I ever knew, Emmett, who died way too young from colon cancer, in his 30s, when I was an emergency medicine resident.
Boseman’s death reignited attention about the rising incidence of colon cancer in young people under the age of 50 and in people of color. Colon cancer is the third most common cancer (excluding skin cancer) and 1 in 5 cases now occur between the ages of 20 and 54. They are not entirely sure why there has been this age shift. Younger people are more likely to be diagnosed with more advanced, later-stage disease. Non-Hispanic Black people have the highest rates of CRC and death across all racial groups in the U.S. The current recommendation is that even average risk individuals undergo CRC screening starting at age 45.
Screening is, by definition, done in asymptomatic individuals. The diagnosis for a screening colonoscopy is Z12.11, Encounter for screening for malignant neoplasm of colon (or some other Z12.1- code indicating a different part of the GI tract). This would be the first-listed diagnosis, and any personal or family history code would be a secondary diagnosis. A positive Cologuard®, guaiac, or hemoccult test is coded as R19.5. The question is: does R19.5, Other fecal abnormalities, constitute a sign or symptom and negate the description of asymptomatic? Does that de facto make the colonoscopy diagnostic?
Approximately 13% of fecal occult blood tests (FOBTs) are false positives. Medicare now “understands both the non-invasive, stool-based test and the follow-on colonoscopy are both part of a continuum of a complete CRC screening.” They no longer invoke cost sharing for follow up colonoscopy after a “Medicare-covered, non-invasive, stool-based CRC screening test returns a positive result.” If cancer or a polyp were to be found and biopsied or removed during the follow up colonoscopy, it would no longer be considered screening but be deemed diagnostic. This would retroactively cause the patient to have to pay 15% of the Medicare approved amount – a whole different can of worms which I am not opening today!
The Medicare Claims Processing Manual was revised in February with an effective date of January 1, 2023, stipulating that, for Medicare, the HCPCS code, G0105 shall be used for CRC screening colonoscopy for an individual who is at high risk, and G0121 shall be used for individuals who do not meet criteria for high risk. A -KX modifier shall be attached to indicate that the service was performed as a follow-on screening after a FOBT positive result. For commercial insurance, the CPT code 45378 should be used with a modifier of -33 indicating preventative services. Screening colonoscopies are not supposed to cost patients anything, removing that barrier.
The 2023 ICD-10-CM Official Guidelines for Coding and Reporting (I.C.21.c.5)) state that testing to rule out or confirm a suspected diagnosis because the patient has some sign or symptom, makes the test a diagnostic examination, not a screening. In that case, the sign or symptom is the reason for the test. If a patient is having a colonoscopy for hematochezia, melena, or abdominal pain, the colonoscopy is diagnostic and you would use those conditions as your diagnosis/es (unless you end up with a definitive diagnosis like a polyp or colitis).
The guidance which is causing us grief is from Coding Clinic 2019, Q1, Vol. 6, No. 1, p. 32. Remember that is from 2019, and the rules changed as of January 1, 2023. There has been no time for Coding Clinic advice to catch up yet.
The Coding Clinic question was what diagnosis to use for a colonoscopy which is negative, which was elicited by a positive Cologuard® test. The response is that you assign R19.5 because “For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient service provided during the encounter/visit.” However, Cologuard® is specified as a screening tool, and it detects blood and/or altered DNA in the stool. Patients can have colonoscopy as a screening either independently or in conjunction with the stool test. If a patient is asymptomatic and has a positive Cologuard® or other screening fecal occult blood test, a follow up colonoscopy is still considered to be screening, not diagnostic.
My opinion, and I will remind you I am not a cooperating party, but I am really good in understanding clinical scenarios and the intent of coding: These patients should have both Z12.1-, Encounter for screening for malignant neoplasm of colon or rectum code and R19.5, Other fecal abnormalities (4/4/23: One of our listeners stated they had contact with Coding Clinic, and they indicated that the Encounter for screening code should be sequenced first). Pertinent personal or family history codes can be additional codes, as well. Then, as long as there is no definitive pathology found during the follow up colonoscopy, use the appropriate CPT/HCPCS code for a screening colonoscopy with the applicable modifier.
To finish this topic off, here are signs and symptoms which might be warning signs of colorectal cancer:
- Discomfort or urge to have a bowel movement; feeling like you haven’t fully evacuated
- Bloody or black stools; rectal bleeding
- A change in bowel habits like new diarrhea or constipation
- Abdominal pain or cramping in lower abdomen
- Decreased appetite or unintended weight loss
- Weakness and fatigue
If you experience any of these, you should see your healthcare provider and undergo a work-up. But you will not be having a screening encounter; this would be diagnostic.
Flier LA, Rico G, Connor YD, Did disparities kill the king of Wakanda? Chadwick Boseman and changing landscape of colon cancer demographics, STST, August 31, 2020. https://www.statnews.com/2020/08/31/disparities-kill-king-of-wakanda-chadwick-boseman-changing-landscape-colon-cancer-demographics/
CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 11865, February 16, 2023. https://www.cms.gov/files/document/r11865cp.pdf
Removal of a National Coverage Determination & Expansion of Coverage of Colorectal Cancer Screening, MLN Matters MM 13017 Revised, Release Date: February 16, 2023, Effective Date: January 1, 2023.
Ensure that you and your patients get reimbursed for eligible CRC screening procedures, American Gastroenterological Association, accessed online March 28, 2023. https://gastro.org/practice-resources/reimbursement/coding/coding-guide-free-crc-screening/
Programming note: Listen to Dr. Erica Remer every Tuesday on Talk Ten Tuesdays when she cohosts the long-running broadcast with Chuck Buck at 10 Eastern.