Colonoscopy and sigmoidoscopy billing
Sedation Options On Oct. 1, 2010, Priority Health began covering all forms of anesthesia services at the preventive coverage level when billed with a screening colonoscopy or sigmoidoscopy. Preventive coverage offers first dollar payment of the claim and minimal, or no, member copayment.
The majority of colonoscopy and sigmoidoscopy cases include conscious sedation monitored and administered by the specialist conducting the procedure. Some cases are conducted with an anesthesia service called monitored anesthesia care (MAC). MAC is provided by an anesthesiologist or CRNA. MAC is billed separately from the specialist services for the colonoscopy or sigmoidoscopy. A third claim may also be billed for facility anesthesia charges.
The decision on which form of sedation is utilized for a colonoscopy or sigmoidoscopy rests with the physician performing the procedure. If the specialist selects MAC as the sedation option, the specialist requests his or her affiliate anesthesiology group to care for the patient during the procedure.
Historically, Priority Health has not covered MAC as a preventive benefit. To improve the member experience, Priority Health will begin covering MAC as a preventive benefit when the colonoscopy or sigmoidoscopy is billed with a screening CPT and ICD-9. This change became effective Oct. 1, 2010.
Colon and rectal cancer screening coverage: preventive screening versus non-preventive American College of Gastroenterology (ACG) guidelines for colonoscopy screening are available on acg.gi.org. General screening guidelines are one every 10 years beginning at age 50, or age 45 for African-American and American Indian populations. More specific guidelines are developed for patients with family history of colon/rectal cancer and personal history of health issues impacting the need for testing outside of general guidelines. To review detailed guidelines, refer to the
Priority Health Colorectal Cancer Screening Medical Policy.
Colorectal cancer screening is considered as testing for a disease in patients who are seemingly well. If a physician is testing a patient based on symptoms or determination of suspected diagnosis, the claim should be coded with a non-preventive ICD-9 code.
Priority Health maps the following codes as preventive. For each of the CPT codes listed below, one of the listed ICD-9 diagnosis codes must also be billed.
- Sigmoidoscopy CPT codes: 45330, 45331, 45333, 45334, 45338, 45339, G0104 (Medicare plans only), G0106 (Medicare plans only)
- Colonoscopy CPT codes: 45378, 45380, 45382-45385, G0105 (Medicare plans only), G0120 (Medicare plans only), G0121 (Medicare plans only)
- Fecal occult blood test CPT codes: 82270, 82274, G0328 (Medicare plans only)
- Preventive/screening ICD-9 diagnosis codes:
- V10.00 Personal history of malignant neoplasm; gastrointestinal tract, unspecified
- V10.01 Personal history of malignant neoplasm; gastrointestinal tract, tongue
- V10.02 Personal history of malignant neoplasm; gastrointestinal tract, other and unspecified oral cavity and pharynx
- V10.03 Personal history of malignant neoplasm; gastrointestinal tract, esophagus
- V10.04 Personal history of malignant neoplasm; gastrointestinal tract, stomach
- V10.05 Personal history of malignant neoplasm; gastrointestinal tract, large intestine
- V10.06 Personal history of malignant neoplasm; gastrointestinal tract, rectum, rectosigmoid junction, and anus
- V16.0 Family history of malignant neoplasm; gastrointestinal tract
- V76.41 Special screening for malignant neoplasms; rectum
- V76.51 Special screening for malignant neoplasms, colon
Preventive coding is appropriate if the colonoscopy or sigmoidoscopy was ordered as screening and a polyp is found and removed. However, the pathology billing of the removed polyp tissue is considered to be non-preventive, and a deductible may apply.
As a provider, you may request a review of colonoscopy and sigmoidoscopy claims that were processed as non-preventive where you consider the member’s case to be preventive. To request a review, please contact your practice’s provider account coordinator. We will ask you for information about the member and claim and request that you provide a copy of the medical records for the colonoscopy or sigmoidoscopy service.
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