Learn the definition of a screening colonoscopy and instructions for coding for a screening colonoscopy and polyp removal in CPT and ICD-10-CM. You will also learn the appropriate use of modifier 33 and how it is applied in the following coding example.
Question: A 60-year-old female patient presents to the outpatient surgery area for a screening colonoscopy. She has no signs or symptoms, nor any personal or family history of polyps or colorectal cancer.
The surgeon inserts a flexible colonoscope into the rectum and advances it through the colon to the cecum. Two polyps are identified. A wire snare loop is slipped around each polyp and the loop is heated to shave off and cauterize the polyps. The mucosal surfaces are observed and no other abnormalities are found. The colonoscope is then removed.
This is a non-Medicare patient. Assign the correct CPT code(s) and ICD-10-CM code(s).
ICD-10-CM: Z12.11, K63.5
Colonoscopy With Polyp Removal
What is a Colonoscopy?
A colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include an examination of the terminal ileum or small intestine proximal to an anastomosis. A colonoscopy can help the physician determine the cause of symptoms such as bleeding from the anus, changes in bowel activity, pain in the abdomen, or unexplained weight loss.
Anastomosis is the surgical connection between two structures. The connection is commonly created between tubular structures such as blood vessels or loops of intestine, according to the U.S National Library of Medicine/MedlinePlus.
According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIH), a screening colonoscopy is also performed in patients with no symptoms and is started at the age of 45 to look for colon polyps and cancer. If the patient has health probems or risk factors that puts them at greater risk of developing colon cancer, the screening colonoscopy may be started at a younger age.
Removal of Polyps During Colonoscopy (Video)
The following video may help you better understand what happens during a colonoscopy and how polyps are removed. The snare technique is discussed.
The documentation states that the patient is seen for a screening colonoscopy (no symptoms and no history). Two polyps are removed.
A screening colonoscopy is considered a preventive service and is performed on a patient without symptoms. Screening exams for non-Medicare patients are reported using CPT conventions, while screening exams for Medicare patients are reported using HCPCS codes (G0105, G1021).
Locate and Verify
In the CPT coding manual Index, look up Colonoscopy, removal, polyp 44392, 44394, 45384-45385.
- 44392, Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
- 44394, Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
- 45384, Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
- 45385, Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
The documentation indicates a flexible colonoscope was inserted and a wire snare loop was used to cauterize the polyps. That eliminates the possibility of codes 44392 and 44394.
Verified in the Tabular, 45385 refers to Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
Even though two polyps were removed in the snare technique, CPT code 45385 should only be reported once.
Per AMA Guidelines:
- Do not report 45385 in conjunction with 45390 for the same lesion
- Do not report 45385 in conjunction with 45378
- For endoscopic mucosal resection, use 45390
Modifier 33, Preventive Services, took effect in 2011 to identify services that are not inherently preventive but are provided as a result of a preventive service.
In the coding scenario above, the patient started out with a screening colonoscopy, and it was converted to a diagnostic colonoscopy due to the discovery of two polyps. Hence, modifier 33 should be appended to the therapeutic screening code for the colonoscopy and removal of polyps (45385-33).
This modifier is only to be used for non-Medicare patients and tells the payor that the therapeutic procedure should be reimbursed without regard to a patient’s copayment or deductible.
The CPT coding manual gives the following description for Modifier 33:
Preventive Services; When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
CPT code 45384 is incorrect, because the code description indicates the polyps were removed by hot biopsy forceps.
Encounter for Screening
Locate and Verify
In the ICD-10-CM coding manual Index, look up Screening (for), colonoscopy Z12.11.
Verified in the Tabular, we can verify our correct code as:
Z12.11, Encounter for screening for malignant neoplasm of colon
Encounter for screening colonoscopy NOS
There are instructional notes at Z12:
- Screening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the disease.
- Use additional code to identify any family history of malignant neoplasm (Z80.-)
- Excludes1: encounter for diagnostic examination-code to sign or symptom
Additional notes provided at Z00-Z13 include:
- Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.
- Excludes1: examinations related to pregnancy and reproduction (Z30-Z36, Z39.-)
According to the ICD-10-CM Official Guidelines for Coding and Reporting:
“Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram).
The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.
A screening code may be a first-listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems. A screening code is not necessary if the screening is inherent to a routine examination, such as a pap smear done during a routine pelvic examination.
Should a condition be discovered during the screening, then the code for the condition may be assigned as an additional diagnosis.
The Z code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.”
A colon polyp forms on the lining of the colon and contains a small clump of cells. According to the Mayo Clinic, these polyps are usually harmless. However, they can develop into colon cancer at some point and may be fatal if not found in the earlier stages.
Locate and Verify
In the ICD-10-CM coding manual Index, look up Polyp, polypus, colon K63.5.
Verified in the Tabular, our correct code is:
K63.5, Polyp of colon
- adenomatous polyp of colon (D12.-)
- inflammatory polyp of colon (K51.4-)
- polyposis of colon (D12.6)
Note: K63.5 is the default code for a colon polyp. If further specificity is provided, such as the location of the polyp, you would assign a different code.
Be sure to read all the notes listed for each code. There is an Excludes2 note to review at K00-K95 which indicates additional codes may need to be assigned.
** This post was reviewed and updated on December 15, 2021. **