ASGE members may submit coding inquiries electronically to codingquestions@asge.org. Each month ASGE gets dozens of questions from members. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and not reports. Below are two questions that could be beneficial to your practice.
Question #1
We have a patient who states that she has a family history of colon cancer due to an aunt’s diagnosis. As we understand it, an aunt is not considered first degree, therefore, she would be average risk but would start the screening process at an earlier age. Is this correct? If so, what is the correct diagnosis code? Diagnosis code Z12.11 is average risk, but, because of the age, it would probably be denied. Does CMS recognize second-degree relatives for screening?
Answer #1
No, CMS only recognizes first-degree relatives. It is up to your physician to decide when the patient needs to be screened earlier than age 45 with a family history of second-degree relatives. Some commercial payers will allow for two or more second-degree relatives to support surveillance, but it is payer and plan specific. Average risk screening would start at age 45 per the new guidelines.
Question #2
An initial polypectomy using a cold snare was incomplete, and therefore required a use of a different device cold biopsy forceps, on the same lesion. Can you bill both the snare and biopsy to CPT code 45380?
Answer #2
Per the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services), chapter 6, section C, # 25 references in the following paragraph, you can only bill for the successful technique to the same lesion. In this case, it would be CPT code 45380. To bill both snare and biopsy, there would have to be two separate lesions treated with separate techniques, one removed by snare and the other removed by cold biopsy forceps.
NCCI Policy Manual Reference:
25. The NCCI PTP edit with Column One CPT code 45385 (Flexible colonoscopy with removal of tumor(s), polyp(s), or lesion(s) by snare technique) and Column Two CPT code 45380 (Flexible colonoscopy with single or multiple biopsies) may be appropriately bypassed using modifier 59 or XS if the 2 procedures are performed on separate lesions. Use of modifier 59 or XE is appropriate if the 2 procedures are performed at separate patient encounters.