Navigating the Changing Landscape of Colonoscopy Billing: New Guidelines, Challenges, and Opportunities
As colorectal cancer rates continue to rise among younger adults, new guidelines recommend that colon cancer screenings begin at age 45 instead of the previous age of 50. This shift in recommendations means that health plans should be prepared for increased costs associated with colonoscopies. The challenges arise when multiple colonoscopy procedures are billed for the same encounter, potentially leading to higher expenses. When reviewed effectively and appropriately, health plans have a potential opportunity to identify waste and abuse, leading to savings. Table 1 outlines the CPT procedure codes for colonoscopies.
Table 1. Colonoscopy CPT codes
| CPT Code | Procedure Description |
|---|---|
| 45378 | Colonoscopy, diagnostic, including brushing or washing |
| 45379 | Colonoscopy, with removal foreign body(s) |
| 45380 | Colonoscopy, with biopsy, single or multiple |
| 45381 | Colonoscopy, with directed submucosal injection(s), any substance |
| 45382 | Colonoscopy, control of bleeding, any method |
| 45384 | Colonoscopy, with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps |
| 45385 | Colonoscopy, with removal of tumor(s), polyp(s), or other lesion(s) by snare technique |
| 45386 | Colonoscopy, with transendoscopic balloon dilation |
| 45388 | Colonoscopy, with ablation of tumor(s), polyp(s), or other lesion(s) |
| 45389 | Colonoscopy, with endoscopic stent placement |
| 45390 | Colonoscopy, with endoscopic mucosal resection |
What should you consider when reviewing multiple colonoscopy procedures?
The AMA CPT code set does an excellent job of defining the intent of the codes in the colonoscopy section. Reviewing multiple colonoscopy procedures submitted during the same encounter doesn’t have to be intimidating when you know the coding conventions – master it!
- Do not report endoscopic mucosal resection (EMR) 45390, with 45380, 45381, 45385, or 45388 for the same lesion as these are bundled into the code for the EMR procedure when performed on the same lesion.
- CPT code 45381 is to be reported separately when the physician performed a saline lift of a polyp before removing the polyp with a snare.
- CPT code 45382 is to be reported separately only for control of spontaneous bleeding which is not the result of a therapeutic intervention. When bleeding is the result of an endoscopic procedure, control of bleeding is not separately reported during the same operative session.
Medical review considerations
- Polypectomies of the same technique are only to be reported once per the CPT code description regardless of the number of polyps, lesions, tumors treated.
- Biopsies of multiple sites are only to be reported once per the CPT code description regardless of the number of sites biopsied.
- When reporting EMR 45390, CPT codes 45380, 45381, 45385, or 45388 are not to be reported separately when performed on the same lesion. Review the diagnoses being reported as well and the total number of pathology units billed to identify a suspicious claim.
- When reporting EMR 45390, CPT 45381 is not to be reported separately as the injection is part of the EMR technique performed.
As always, please verify your plan’s policy and guidance and adjust your query for any of the services presented in this document before taking further action.
What are some examples of colonoscopies in an outpatient hospital setting that may warrant further examination?
Scenario 1 – Multiple colonoscopy procedures
A patient undergoes screening colonoscopy in a hospital outpatient department. The hospital submits a claim with the following procedures:
- Colon biopsy (45380)
- Snare polypectomy (45385)
- Directed submucosal injection (45381)
- Propofol (J2704)
- Lidocaine IV (J2001)
- Phenylephrine HCL (J2370)
- Epinephrine (J0171)
Could the providers be reporting 45381 when they really are performing 45382 for control of bleeding incorrectly to gain reimbursement? The diagnoses on the claim [D120 – D129] reflect a benign polyp of the transverse and descending colon in addition to cancer of cecum and a family history of malignancy of digestive system. The procedures billed in this claim suggest incorrect reporting of 45381 as there is no saline being reported to support a saline lift of the polyps removed by snare technique. The hospital billed epinephrine, which is used mainly to control bleeding that occurs after a polypectomy. A medical record review would be warranted to ensure 45381 is supported. If the outpatient hospital is billing 45381 instead of 45382, which is not separately reportable if the bleeding is caused by the intervention. As such, 45381 should not be reimbursed, which is the opportunity for savings, either in a pre-pay review or post-pay audit.
Scenario 2 – EMR with a colonoscopy procedure
A patient undergoes screening colonoscopy in a hospital outpatient department. The hospital submits a claim with the following procedures:
- Antibody stain (88342)
- Pathology (88305)
- IV lidocaine (J2001)
- Propofol (J2704)
- Fentanyl (J3010)
- Directed submucosal injection (45381)
- Endoscopic mucosal resection (45390)
In this case, the facility billed for 45390 in addition to 45381. If this is performed on the same lesion, the injection is not separately reportable. The outpatient hospital did apply modifier XU (unusual non-overlapping service) to code 45381. This claim is suspicious for unbundling of 45381 because the reported diagnosis [D122 – benign neoplasm colon, with no other lesion] and the fact that only one removal code is being reported. It is likely there is only one lesion being addressed at this encounter. Even in the event the physician performs a tattooing at the site of the EMR, the tattooing procedure is not separately reportable when performed at the same lesion site. The claim line for 45381 should be denied and we should consider reviewing the provider for inappropriate modifier usage.
How can Codoxo’s Forensic Platform Query tool assist your health plan with identifying possible inappropriate multiple colonoscopy procedures?
Fraud Scope can identify facility providers that submit claims for multiple colonoscopies or EMR with a colonoscopy using the Frequent Combinations AI detector.
Additionally, the Query tool allows users to customize the criteria to easily identify multiple colonoscopy procedures submitted on the same claim that might be suspicious or inappropriate to bill together. Navigate to Query and choose Facility, Claims with the following criteria:
Scenario 1 – Multiple colonoscopies
- Procedure Code, Select Custom Editor = (45385 AND 45380) AND (45378 OR 45379 OR 45381 OR 45382 OR 45383 OR 45384 OR 45386 OR 45387 OR 45388 OR 45389 OR 45390)
- Begin service date = Choose start date or range of dates that are pertinent to your review period
- Provider Payment Received = Within this Range [Minimum Amount = 1]
- Type of Bill, Select Custom Editor = 013* OR 085*
- If your plan does not use leading zeroes = 13* OR 85*
- Click Search to see the results
Scenario 2 – EMR with a colonoscopy
- Procedure Code, Select Custom Editor = 45390 AND (45380 OR 45381 OR 45385 OR 45398 OR 45378)
- Begin service date = Choose start date or range of dates that are pertinent to your review period
- Provider Payment Received = Within this Range [Minimum Amount = 1]
- Type of Bill, Select Custom Editor = 013* OR 083* OR 085*
- If your plan does not use leading zeroes = 13* OR 83* OR 85*
- Click Search to see the results
References:
United States Preventive Service Task Force [Screening Age Recommendations]
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
CMS MLN Matters February 2023 [NCD 160.22 updates]
Becker’s Hospital [ASC colonoscopy billing violations]